MEDICARE: VITAL CARE TELE NP 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	:	1124852173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL CARE TELE NP LLC

Provider Business Mailing Address
First Line	:	6826 ALISO AVE
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33413-1036
Country	:	US
Telephone Number	:	561-503-0309
Fax Number	:

Provider Business Practice Location Address
First Line	:	6826 ALISO AVE
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33413-1036
Country	:	US
Telephone Number	:	561-503-0309
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEBBIE SIMONE GORDON
Credential	:
Telephone Number	:	561-503-0309

Provider Enumeration Date	:	08/30/2024
Last Update Date	:	10/30/2024

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