MEDICARE: VITAL IOM 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	247200000X	Other Technician

General Provider Information

NPI Number	:	1467812396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL IOM LLC

Provider Business Mailing Address
First Line	:	17194 PRESTON RD STE 120
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-1203
Country	:	US
Telephone Number	:	972-733-9955
Fax Number	:	972-733-9935

Provider Business Practice Location Address
First Line	:	17194 PRESTON RD STE 120
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-1203
Country	:	US
Telephone Number	:	972-733-9955
Fax Number	:	972-733-9935

Authorized Official
Title or Position	:	CEO
Name	:	ZACH LENZ
Credential	:
Telephone Number	:	972-733-9955

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	03/04/2016

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Directions to “VITAL IOM LLC ” Practice Location

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