MEDICARE: VITAL IMPACT HEALTHCARE, 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	305R00000X	Preferred Provider Organization
2	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1447014881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL IMPACT HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	1108 BELL SHOALS RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-8813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 BELL SHOALS RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-8813
Country	:	US
Telephone Number	:	813-359-8787
Fax Number	:	813-359-8788

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. ROGER BROWN
Credential	:
Telephone Number	:	561-302-6086

Provider Enumeration Date	:	02/07/2024
Last Update Date	:	02/07/2024

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