MEDICARE: VITALITY HEALTH SERVICES 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1790539591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	2254 LAVISTA SQ NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3768
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2254 LAVISTA SQ NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3768
Country	:	US
Telephone Number	:	347-552-4976
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEVON WHITTAKER
Credential	:
Telephone Number	:	347-552-4976

Provider Enumeration Date	:	04/16/2024
Last Update Date	:	04/16/2024

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