Healthcare Provider Details

I. General information

NPI: 1952068843
Provider Name (Legal Business Name): VITAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CLINTON ST
MAUMEE OH
43537-2811
US

IV. Provider business mailing address

111 CLINTON ST
MAUMEE OH
43537-2811
US

V. Phone/Fax

Practice location:
  • Phone: 197-403-0224
  • Fax: 419-740-3033
Mailing address:
  • Phone: 419-740-3022
  • Fax: 419-740-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICOLE M SPELLIS-FREYRE
Title or Position: AUTHORIZED OFFICIAL
Credential: CRNP
Phone: 419-740-3022