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General NPI Number Information
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NPI Number | 1053109710
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Entity Type | Organization
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Legal Business Name | VITALMEDIX SUPPLIES LLC
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Dates
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Enumeration Date | 04/30/2025
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 10616 E WINNER RD
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City | INDEPENDENCE
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State | MO
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Zip | 64052-2203
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Country | US
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Telephone | 872-331-8174
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Fax |
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Provider Business Mailing Address
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Address Line | 10616 E 18TH ST S STE 402
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City | INDEPENDENCE
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State | MO
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Zip | 64052-2203
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER/PRESIDENT
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Name | UNKNOWN MOHAMMED MOHIUDDIN AHMED
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Credential |
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Telephone | 872-331-8174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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