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General NPI Number Information
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NPI Number | 1851097406
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Entity Type | Organization
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Legal Business Name | VITALITY FAMILY HEALTHCARE, LLC
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Dates
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Enumeration Date | 02/06/2023
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 1028 N WEBB RD STE E
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City | GRAND ISLAND
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State | NE
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Zip | 68803-3318
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Country | US
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Telephone | 308-865-0703
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Fax | 308-865-0703
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Provider Business Mailing Address
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Address Line | 521 WEST AVE
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City | HOLDREGE
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State | NE
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Zip | 68949-2226
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Country | US
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Telephone | 308-865-0703
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Fax | 308-865-0703
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Authorized Official
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Title or Position | CEO, PHYSICIAN
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Name | DR. JACOB CHRISTOPHER PETERSON
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Credential | MD
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Telephone | 308-865-0703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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