MEDICARE: VITALGENIX HEALTH & WELLNESS, 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1427428887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALGENIX HEALTH & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	1325 S INTERNATIONAL PKWY
Second Line	:	SUITE 2241
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1695
Country	:	US
Telephone Number	:	407-636-9663
Fax Number	:	407-636-9664

Provider Business Practice Location Address
First Line	:	1325 S INTERNATIONAL PKWY
Second Line	:	SUITE 2241
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1695
Country	:	US
Telephone Number	:	407-636-9663
Fax Number	:	407-636-9664

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAUL ENRIQUE TAMAYO
Credential	:	M.D.
Telephone Number	:	407-636-9663

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	09/29/2015

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