Provider Demographics
NPI:1730532359
Name:VITA FAMILY MEDICINE AND MEDSPA LLC
Entity type:Organization
Organization Name:VITA FAMILY MEDICINE AND MEDSPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-805-8264
Mailing Address - Street 1:540 FORT EVANS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3379
Mailing Address - Country:US
Mailing Address - Phone:703-737-3500
Mailing Address - Fax:703-737-3550
Practice Address - Street 1:540 FORT EVANS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3379
Practice Address - Country:US
Practice Address - Phone:703-737-3500
Practice Address - Fax:703-737-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101258315261QP2300X
VA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG155Medicare PIN