Healthcare Provider Details

I. General information

NPI: 1659165405
Provider Name (Legal Business Name): VITALIS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2193 EAGLECLOUD DR
HENDERSON NV
89074-1801
US

IV. Provider business mailing address

2193 EAGLECLOUD DR
HENDERSON NV
89074-1801
US

V. Phone/Fax

Practice location:
  • Phone: 702-418-9965
  • Fax:
Mailing address:
  • Phone: 702-418-9965
  • 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 Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: YAMERI MONASTERIOS AMPARAN
Title or Position: MANAGER
Credential:
Phone: 702-418-9965