Healthcare Provider Details

I. General information

NPI: 1417647066
Provider Name (Legal Business Name): VITAL FAMILY HEALTHCARE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 04/12/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 LOGAN AVE
BELVIDERE IL
61008
US

IV. Provider business mailing address

1004 LOGAN AVE
BELVIDERE IL
61008-3955
US

V. Phone/Fax

Practice location:
  • Phone: 815-482-6365
  • Fax:
Mailing address:
  • Phone: 815-482-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACLYN NEWHART
Title or Position: MANAGER
Credential:
Phone: 815-482-6365