MEDICARE: VITALITY HEALTH GROUP

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	207RC0000X	Cardiovascular Disease Physician	01029301A	IN

General Provider Information

NPI Number	:	1154550143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY HEALTH GROUP

Provider Business Mailing Address
First Line	:	1702 W MICHIGAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-3983
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1702 W MICHIGAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-3983
Country	:	US
Telephone Number	:	317-652-2147
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RAY L HENDERSON
Credential	:
Telephone Number	:	317-652-2147

Provider Enumeration Date	:	07/10/2009
Last Update Date	:	07/10/2009

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