MEDICARE: VITALITY CHIROPRACTIC, INC.

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	111N00000X	Chiropractor	DC 21229	CA

General Provider Information

NPI Number	:	1356500243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	6940 SANTA TERESA BLVD
Second Line	:	#2
City	:	SAN JOSE
State	:	CA
Zip	:	95119-1345
Country	:	US
Telephone Number	:	408-363-1991
Fax Number	:

Provider Business Practice Location Address
First Line	:	6940 SANTA TERESA BLVD
Second Line	:	#2
City	:	SAN JOSE
State	:	CA
Zip	:	95119-1345
Country	:	US
Telephone Number	:	408-363-1991
Fax Number	:

Authorized Official
Title or Position	:	CHIRPRACTOR
Name	:	DAVID BASISTA
Credential	:	D.C.
Telephone Number	:	408-363-1991

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	06/05/2008

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