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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1942891205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY MEDICAL, LLC

Provider Business Mailing Address
First Line	:	2060 OVERLAND AVE STE 1A
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59102-6439
Country	:	US
Telephone Number	:	406-855-2422
Fax Number	:	406-702-1624

Provider Business Practice Location Address
First Line	:	2060 OVERLAND AVE STE 1A
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59102-6439
Country	:	US
Telephone Number	:	406-855-2422
Fax Number	:	406-204-5595

Authorized Official
Title or Position	:	OWNER
Name	:	MELISSA LYNN FULLER
Credential	:	DNP
Telephone Number	:	406-671-0184

Provider Enumeration Date	:	01/29/2021
Last Update Date	:	07/24/2024

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