MEDICARE: VITAL LIFE VIRTUAL CARE

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1609497734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL LIFE VIRTUAL CARE

Provider Business Mailing Address
First Line	:	2511 W CHURCH ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32805-2329
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2511 W CHURCH ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32805-2329
Country	:	US
Telephone Number	:	321-235-0692
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	GABRIEL NURIEL
Credential	:	D.O
Telephone Number	:	321-235-0692

Provider Enumeration Date	:	04/29/2020
Last Update Date	:	04/29/2020

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Directions to “VITAL LIFE VIRTUAL CARE ” Practice Location

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