=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497149066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITA HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2015
-----------------------------------------------------
Last Update Date | 03/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 6TH AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50314-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-244-1895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1725 6TH AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50314-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-244-1895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GINA BELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-333-3463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 770488
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------