Healthcare Provider Details

I. General information

NPI: 1104693969
Provider Name (Legal Business Name): VITALITY MEDICAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2219 SAWDUST RD STE 302
SPRING TX
77380-2576
US

IV. Provider business mailing address

2219 SAWDUST RD STE 302
SPRING TX
77380-2576
US

V. Phone/Fax

Practice location:
  • Phone: 832-245-9892
  • Fax: 321-323-3740
Mailing address:
  • Phone: 832-245-9892
  • Fax: 321-323-3740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MEGAN ELIZABETH MOHSIN
Title or Position: CO-OWNER
Credential:
Phone: 386-344-1538