MEDICARE: VIP IV & MEDICAL SPA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1447932280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIP IV & MEDICAL SPA, LLC

Provider Business Mailing Address
First Line	:	1747 LOS LAGOS DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6625
Country	:	US
Telephone Number	:	480-404-4896
Fax Number	:	480-400-1063

Provider Business Practice Location Address
First Line	:	1690 MCCULLOCH BLVD N STE 102
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6560
Country	:	US
Telephone Number	:	480-404-4896
Fax Number	:	480-400-1063

Authorized Official
Title or Position	:	OWNER, FAMILY NURSE PRACTITIONER
Name	:	MS. KELLEY ROBIN FARLEY
Credential	:	FNP-C
Telephone Number	:	480-404-4896

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	01/11/2024

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