MEDICARE: VITALITY MEDICAL CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1073340030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MEDICAL CARE LLC

Provider Business Mailing Address
First Line	:	1754 E TANO LN
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-1718
Country	:	US
Telephone Number	:	847-910-6059
Fax Number	:

Provider Business Practice Location Address
First Line	:	1754 E TANO LN
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-1718
Country	:	US
Telephone Number	:	847-910-6059
Fax Number	:	360-554-0143

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL CASTANEDA
Credential	:	APN
Telephone Number	:	847-910-6059

Provider Enumeration Date	:	09/16/2024
Last Update Date	:	09/16/2024

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Directions to “VITALITY MEDICAL CARE LLC ” Practice Location

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