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General NPI Number Information
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NPI Number | 1710517347
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Entity Type | Organization
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Legal Business Name | VITAL MED LLC
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Dates
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Enumeration Date | 01/23/2020
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Last Update Date | 01/23/2020
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Provider Practice Location Address
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Address Line | 103 RIDGEMONT VILLA
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City | BOONEVILLE
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State | MS
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Zip | 38829-1010
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Country | US
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Telephone | 662-368-3858
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Fax | 662-368-3931
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Provider Business Mailing Address
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Address Line | 103 RIDGEMONT VILLA
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City | BOONEVILLE
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State | MS
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Zip | 38829-1010
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Country | US
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Telephone | 662-368-3858
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Fax | 662-368-3931
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Authorized Official
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Title or Position | OWNER/NP
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Name | DESIREE BROOKE HAUGH
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Credential | NP
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Telephone | 662-368-3858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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