=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861337511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW GENESIS VITALITY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2026
-----------------------------------------------------
Last Update Date | 04/21/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10601 CLARENCE DR STE 250
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-3867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-401-8001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10601 CLARENCE DR STE 250
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-3867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-401-8001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | KEITH A KIRBOW
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 903-806-1060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------