Vital Prosthetics, Inc.

Primary specialty

Prosthetic/Orthotic SupplierTaxonomy code 335E00000X

License

PRO 66 Issued in FL

Legal business name

VITAL PROSTHETICS, INC.

Practice address

4299 3Rd Ave
Marianna, FL 32446-2136

Phone

(850) 526-0063

Fax

(850) 526-1317

NPI assigned

Jun 26, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Dale E Petersen Jr., CPNPI 1184827693

Title

Pres/Owner

Phone

(850) 526-0063

Specialties & licenses 1

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Dale Edmund Petersen Jr., CP

  • Prosthetist
  • Marianna, FL
  • NPI 1184827693
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1214438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1221696000000",
    "number": "1114189669",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 430",
            "city": "MARIANNA",
            "state": "FL",
            "postal_code": "324470430",
            "telephone_number": "850-526-0063",
            "fax_number": "850-526-1317"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4299 3RD AVE",
            "city": "MARIANNA",
            "state": "FL",
            "postal_code": "324462136",
            "telephone_number": "850-526-0063",
            "fax_number": "850-526-1317"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VITAL PROSTHETICS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-26",
        "last_updated": "2008-09-18",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "DALE",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PRES/OWNER",
        "authorized_official_telephone_number": "850-526-0063",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "CP"
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": "FL",
            "license": "PRO 66",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Prosthetic/Orthotic Supplier in Marianna, FL
• Providers in Marianna, FL by specialty
• Prosthetic/Orthotic Supplier in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.