Provider Demographics
NPI:1144434622
Name:VITALE, STEVEN THOMAS (CPO)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:THOMAS
Last Name:VITALE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W ORANGEBURG AVE
Mailing Address - Street 2:STE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4163
Mailing Address - Country:US
Mailing Address - Phone:209-575-1063
Mailing Address - Fax:209-575-1065
Practice Address - Street 1:1005 W ORANGEBURG AVE
Practice Address - Street 2:STE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4163
Practice Address - Country:US
Practice Address - Phone:209-575-1063
Practice Address - Fax:209-575-1065
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO2516225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0151460Medicaid