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General NPI Number Information
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NPI Number | 1053225953
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Entity Type | Organization
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Legal Business Name | VITA LUXE, LLC
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Dates
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Enumeration Date | 09/29/2026
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Last Update Date | 09/29/2026
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Provider Practice Location Address
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Address Line | 6322 S 3000 E STE 170
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City | SALT LAKE CITY
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State | UT
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Zip | 84121-7290
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Country | US
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Telephone | 801-513-3223
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Fax |
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Provider Business Mailing Address
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Address Line | 6322 S 3000 E STE 170
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City | SALT LAKE CITY
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State | UT
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Zip | 84121-7290
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Country | US
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Telephone | 801-513-3223
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. JEREMY POULSEN
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Credential |
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Telephone | 559-313-6472
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State | NULL
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