Healthcare Provider Details

I. General information

NPI: 1750858403
Provider Name (Legal Business Name): VITALITY GENERATION & MIDWIFERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 12/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5319 S 500 E STE C
OGDEN UT
84405
US

IV. Provider business mailing address

431 E 2700 N
OGDEN UT
84414
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-6104
  • Fax: 801-436-5182
Mailing address:
  • Phone: 801-628-4573
  • Fax: 801-436-5182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORETTA S. SHUPE
Title or Position: CEO
Credential: CPM
Phone: 801-628-4573