=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821490335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITANOVU, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2014
-----------------------------------------------------
Last Update Date | 01/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 S OWYHEE ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-344-8482
-----------------------------------------------------
Fax | 208-345-5426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 S OWYHEE ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-344-8482
-----------------------------------------------------
Fax | 208-345-5426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OWNER
-----------------------------------------------------
Name | JENIFER LEAH BARRY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-344-8482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | M-11233
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------