Healthcare Provider Details

I. General information

NPI: 1245041813
Provider Name (Legal Business Name): BELLA VITA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8812 E PALM LN
MESA AZ
85207-9113
US

IV. Provider business mailing address

PO BOX 1503
QUEEN CREEK AZ
85142-1833
US

V. Phone/Fax

Practice location:
  • Phone: 480-269-7906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: CODY KNUDSON
Title or Position: MEMBER
Credential:
Phone: 480-269-7906