Healthcare Provider Details

I. General information

NPI: 1467661157
Provider Name (Legal Business Name): VITALSURGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W 42ND ST
JOPLIN MO
64804-4564
US

IV. Provider business mailing address

702 W 42ND ST
JOPLIN MO
64804-4564
US

V. Phone/Fax

Practice location:
  • Phone: 417-206-0105
  • Fax:
Mailing address:
  • Phone: 417-206-0105
  • Fax: 417-206-0109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MR. DICK WEBER
Title or Position: CEO PRESIDENT
Credential:
Phone: 417-206-0105