=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457907404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALITY WELLNESS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 SANGER AVE STE 211
-----------------------------------------------------
City | OCEANPORT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07757-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-462-3812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 68 WHITE ST # 7272
-----------------------------------------------------
City | RED BANK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07701-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MR. SCOTT CAROTNEUTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-462-3812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QC1800X
-----------------------------------------------------
Taxonomy Name | Corporate Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------