VITALITY CLINICS OF EAST TEXAS, P.A. - NPI NUMBER 1508206442

Summary

Provider Name: VITALITY CLINICS OF EAST TEXAS, P.A.

NPI Number: 1508206442

Clasification: Family Medicine (207QA0505X)

Specialization: Adult Medicine

Address:
455 RICE RD
102
TYLER, TX
ZIP 75703

Phone Number: (903) 525-9432



Detailed Information

VITALITY CLINICS OF EAST TEXAS, P.A. is an adult family physician in Tyler, TX. The provider is definition to come. The assigned NPI number for this provider is 1508206442 and is registered as an organization entity type and is a single specialty group.

The provider's business address is:

455 RICE RD
102
TYLER, TX
ZIP 75703-604
Phone: (903) 525-9432
Fax: (903) 525-9455

The provider's authorized official is Steven Kip Yoder .
The authorized official title is Owner and has the following contact phone number (903) 525-9432.

The enumeration date for this NPI number is 6/25/2013 and was last updated on 6/25/2013.

Map - Location of Practice

Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 207QA0505X Family Medicine Adult Medicine Yes

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1508206442 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name VITALITY CLINICS OF EAST TEXAS, P.A. The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider First Line Business Practice Location Address 455 RICE RD The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
6 Provider Second Line Business Practice Location Address 102 The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
7 Provider Business Practice Location Address City Name TYLER The city name in the location address of the provider being identified.
8 Provider Business Practice Location Address State Name TX The State code in the location of the provider being identified.
9 Provider Business Practice Location Address Postal Code 757033604 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
10 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
11 Provider Business Practice Location Address Telephone Number 9035259432 The telephone number associated with the location address of the provider being identified.
12 Provider Business Practice Location Address Fax Number 9035259455 The fax number associated with the location address of the provider being identified.
13 Provider Enumeration Date 6/25/2013 The date the provider was assigned a unique identifier (assigned an NPI).
14 Last Update Date 6/25/2013 The date that a record was last updated or changed.
15 Authorized Official Last Name YODER The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
16 Authorized Official First Name STEVEN The first name of the authorized official.
17 Authorized Official Middle Name KIP The middle name of the authorized official.
18 Authorized Official Title or Position OWNER The title or position of the authorized official.
19 Authorized Official Telephone Number 9035259432 The 10-position telephone number of the authorized official.
20 Healthcare Provider Taxonomy Code 1 207QA0505X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
21 Healthcare Provider Primary Taxonomy Switch 1 Y
22 Is Organization Subpart N
23 Authorized Official Name Prefix Text DR.
24 Authorized Official Credential Text M.D.
25 Healthcare Provider Taxonomy Group 1 193400000X SINGLE SPECIALTY GROUP

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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