Healthcare Provider Details

I. General information

NPI: 1689430407
Provider Name (Legal Business Name): VITALITY HEALTH CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 S BEECH DALY ST STE 102
DEARBORN HEIGHTS MI
48125-1576
US

IV. Provider business mailing address

4245 S BEECH DALY ST
DEARBORN HEIGHTS MI
48125-1576
US

V. Phone/Fax

Practice location:
  • Phone: 313-414-0703
  • Fax:
Mailing address:
  • Phone: 313-414-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAWYA KAZAN
Title or Position: NURSE PRACTITIONER
Credential: AGPCNP-BC
Phone: 313-414-0703