Healthcare Provider Details

I. General information

NPI: 1770954703
Provider Name (Legal Business Name): VITALITY HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2015
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5717 OAKLAND DR STE A
PORTAGE MI
49024-1116
US

IV. Provider business mailing address

5717 OAKLAND DR STE A
PORTAGE MI
49024-1116
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-4473
  • Fax: 269-324-0755
Mailing address:
  • Phone: 269-323-4473
  • Fax: 269-324-0755

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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES T JOSEPH
Title or Position: PRESIDENT
Credential: MD
Phone: 269-323-4473