Healthcare Provider Details

I. General information

NPI: 1821517954
Provider Name (Legal Business Name): VITALITY FUNCTIONAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 SW CENTURY DR STE 111
BEND OR
97702-1657
US

IV. Provider business mailing address

19657 ASPEN RIDGE DR
BEND OR
97702-3366
US

V. Phone/Fax

Practice location:
  • Phone: 458-206-3331
  • Fax: 620-506-4777
Mailing address:
  • Phone: 561-676-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201706673NP
License Number StateOR

VIII. Authorized Official

Name: ERIN ARNOLD BISHOP
Title or Position: NURSE PRACTITIONER
Credential: GNP-BC, FNP-C
Phone: 561-676-6121