Healthcare Provider Details

I. General information

NPI: 1194212977
Provider Name (Legal Business Name): VITALITY INTERNAL MEDICINE - AVONDALE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10320 W MCDOWELL RD STE E5015
AVONDALE AZ
85392-4869
US

IV. Provider business mailing address

111 E DUNLAP AVE STE 1-193
PHOENIX AZ
85020-7812
US

V. Phone/Fax

Practice location:
  • Phone: 602-791-9112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES BENJAMIN EVANS II
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 602-791-9112