=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699214569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALIS HOME HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9821 SUMMERWOOD CIR APT 1308
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-390-6884
-----------------------------------------------------
Fax | 972-476-0870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9821 SUMMERWOOD CIR APT 1308
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-7742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-390-6884
-----------------------------------------------------
Fax | 972-476-0870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINITRATOR
-----------------------------------------------------
Name | MR. DESMOND O ARREY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-390-6884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 015415
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------