=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548489024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALANT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 10/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10536 PETER A MCCUEN BLVD
-----------------------------------------------------
City | MATHER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95655-4128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-456-1500
-----------------------------------------------------
Fax | 916-366-0791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10536 PETER A MCCUEN BLVD
-----------------------------------------------------
City | MATHER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95655-4128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-456-1500
-----------------------------------------------------
Fax | 916-366-0791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF LEGAL & RISK OFFICER
-----------------------------------------------------
Name | BHAVI A SHAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-675-5653
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 331L00000X
-----------------------------------------------------
Taxonomy Name | Blood Bank
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 05D0615608
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------