Healthcare Provider Details

I. General information

NPI: 1740119197
Provider Name (Legal Business Name): VIP IV WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 E WILLIAMS FIELD RD STE 105
GILBERT AZ
85295-1824
US

IV. Provider business mailing address

1530 E WILLIAMS FIELD RD STE 105
GILBERT AZ
85295-1824
US

V. Phone/Fax

Practice location:
  • Phone: 480-740-1910
  • Fax:
Mailing address:
  • Phone: 480-740-1910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICK SMITH
Title or Position: MANAGER
Credential:
Phone: 480-740-1910