Healthcare Provider Details

I. General information

NPI: 1134550825
Provider Name (Legal Business Name): VITAL4MEN CHANDLER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 S DOBSON RD BLDG. B SUITE #216
CHANDLER AZ
85224-5667
US

IV. Provider business mailing address

7707 W DEER VALLEY RD STE 115
PEORIA AZ
85382-2101
US

V. Phone/Fax

Practice location:
  • Phone: 623-399-8606
  • Fax: 623-399-9958
Mailing address:
  • Phone: 623-399-8606
  • Fax: 623-399-9958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number15568
License Number StateAZ

VIII. Authorized Official

Name: KEVIN WRAY
Title or Position: MEMBER
Credential:
Phone: 623-399-8606