Healthcare Provider Details

I. General information

NPI: 1124660444
Provider Name (Legal Business Name): VITALITY HEALTH SYSTEMS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 RICHMOND RD STE 202
RICHMOND HEIGHTS OH
44143-2704
US

IV. Provider business mailing address

464 RICHMOND RD STE 202
RICHMOND HEIGHTS OH
44143-2704
US

V. Phone/Fax

Practice location:
  • Phone: 330-824-4200
  • Fax: 440-525-5564
Mailing address:
  • Phone: 330-824-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLI BLACK
Title or Position: BILLING MANAGER
Credential:
Phone: 216-512-5929