MEDICARE: VITALIS HEALTH

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	261QM0801X	Mental Health (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1417598517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALIS HEALTH

Provider Business Mailing Address
First Line	:	3091 BATTLEFIELD PKWY
Second Line	:
City	:	FT OGLETHORPE
State	:	GA
Zip	:	30742-4003
Country	:	US
Telephone Number	:	706-841-0500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3091 BATTLEFIELD PKWY
Second Line	:
City	:	FT OGLETHORPE
State	:	GA
Zip	:	30742-4003
Country	:	US
Telephone Number	:	423-902-9667
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DENISE GOODWIN
Credential	:	FNP
Telephone Number	:	423-902-9667

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	08/21/2020

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