=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386319994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANT MEDICAL CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7702 PITKIN AVE
-----------------------------------------------------
City | OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11417-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-709-0010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7702 PITKIN AVE
-----------------------------------------------------
City | OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11417-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-709-0010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH F DAMORE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 631-871-2160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------