Healthcare Provider Details

I. General information

NPI: 1851097406
Provider Name (Legal Business Name): VITALITY FAMILY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 N WEBB RD STE E
GRAND ISLAND NE
68803-3318
US

IV. Provider business mailing address

521 WEST AVE
HOLDREGE NE
68949-2226
US

V. Phone/Fax

Practice location:
  • Phone: 308-865-0703
  • Fax: 308-865-0703
Mailing address:
  • Phone: 308-865-0703
  • Fax: 308-865-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB CHRISTOPHER PETERSON
Title or Position: CEO, PHYSICIAN
Credential: MD
Phone: 308-865-0703