Healthcare Provider Details

I. General information

NPI: 1366202764
Provider Name (Legal Business Name): VITALIZE MEDICAL VASCULAR AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 CHERRY LANE
LAUREL MD
20708
US

IV. Provider business mailing address

9201 CHERRY LANE
LAUREL MD
20708
US

V. Phone/Fax

Practice location:
  • Phone: 301-497-1590
  • Fax: 240-334-4781
Mailing address:
  • Phone: 301-497-1590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AYANA SEIBLES
Title or Position: OWNER
Credential: DO
Phone: 301-497-1590