Healthcare Provider Details

I. General information

NPI: 1457591182
Provider Name (Legal Business Name): VITALITY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8785 W. WARM SPRINGS RD. SUITE 109
LAS VEGAS NV
89148-1823
US

IV. Provider business mailing address

8785 W WARM SPRINGS RD SUITE 109
LAS VEGAS NV
89148-1823
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-1200
  • Fax: 702-736-6302
Mailing address:
  • Phone: 702-731-1200
  • Fax: 702-736-6302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number5456
License Number StateNV

VIII. Authorized Official

Name: SAMUEL ANTONIO MUJICA TRENCHE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 702-731-1200