Provider Demographics
NPI:1487086914
Name:TOTAL VITALITY MEDICAL GROUP LLC
Entity type:Organization
Organization Name:TOTAL VITALITY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTBYL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-1460
Mailing Address - Street 1:24945 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-3927
Mailing Address - Country:US
Mailing Address - Phone:727-726-1460
Mailing Address - Fax:727-724-9705
Practice Address - Street 1:24945 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-3927
Practice Address - Country:US
Practice Address - Phone:727-726-1460
Practice Address - Fax:727-724-9705
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNCOAST TOTAL HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service