MEDICARE: VITALITY MEDICAL CENTER INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363L00000X	Nurse Practitioner
2	207P00000X	Emergency Medicine Physician
3	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C4208588	OTHER	CA	CORPORATION NUMBER

General Provider Information

NPI Number	:	1184198442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	1648 W GLENOAKS BLVD # 101
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91201-1827
Country	:	US
Telephone Number	:	818-805-0005
Fax Number	:	818-805-0050

Provider Business Practice Location Address
First Line	:	1648 W GLENOAKS BLVD # 101
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91201-1827
Country	:	US
Telephone Number	:	818-805-0005
Fax Number	:	818-805-0050

Authorized Official
Title or Position	:	SECRETARY
Name	:	LILIA SEROBIAN
Credential	:
Telephone Number	:	818-805-0005

Provider Enumeration Date	:	01/18/2019
Last Update Date	:	01/18/2019

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Directions to “VITALITY MEDICAL CENTER INC ” Practice Location

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