=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730657271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALITY AGELESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2018
-----------------------------------------------------
Last Update Date | 05/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | VITALITY AGELESS CENTER LLC 1300 PEACHTREE INDUSTRIAL BLVD #1201
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-4686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-614-6266
-----------------------------------------------------
Fax | 770-623-9949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 PEACHTREE INDUSTRIAL BLVD STE 1201
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-614-6266
-----------------------------------------------------
Fax | 770-623-9949
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JULIE YU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-614-6266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------