MEDICARE: VITALWAVE HEALTHCARE INC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1720855620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALWAVE HEALTHCARE INC

Provider Business Mailing Address
First Line	:	5901 N CICERO AVE STE 608
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5721
Country	:	US
Telephone Number	:	714-768-8645
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 N CICERO AVE STE 608
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5721
Country	:	US
Telephone Number	:	714-768-8645
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	ABDUL LATHEEF
Credential	:
Telephone Number	:	714-768-8645

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	12/11/2023

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