=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003705211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE VITALITY WELLNESS, NURSING PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2025
-----------------------------------------------------
Last Update Date | 07/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3231 W 132ND ST
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-387-2410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3231 W 132ND ST
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO & PRESIDENT
-----------------------------------------------------
Name | ERICA VEGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-387-2410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------