MEDICARE: VITALITY MEDICAL 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	2083B0002X	Obesity Medicine (Preventive Medicine) Physician	2014-01121	NC

General Provider Information

NPI Number	:	1639539455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MEDICAL LLC

Provider Business Mailing Address
First Line	:	12228 JOURNEYS END TRL
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-2422
Country	:	US
Telephone Number	:	704-895-5448
Fax Number	:	704-896-1761

Provider Business Practice Location Address
First Line	:	16415 NORTHCROSS DR
Second Line	:	SUITE A
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-5001
Country	:	US
Telephone Number	:	704-895-5448
Fax Number	:	704-896-1761

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASON R PATTEN
Credential	:	MD
Telephone Number	:	334-717-1073

Provider Enumeration Date	:	03/07/2016
Last Update Date	:	03/07/2016

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