=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467812396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL IOM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2016
-----------------------------------------------------
Last Update Date | 03/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17194 PRESTON RD STE 120
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75248-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-733-9955
-----------------------------------------------------
Fax | 972-733-9935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17194 PRESTON RD STE 120
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75248-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-733-9955
-----------------------------------------------------
Fax | 972-733-9935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ZACH LENZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-733-9955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------