Healthcare Provider Details

I. General information

NPI: 1497421101
Provider Name (Legal Business Name): VITALIS WELLNESS CENTER OF PHOENIX, AZ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2021
Last Update Date: 07/19/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 S STAPLEY DR STE 120
MESA AZ
85204-6676
US

IV. Provider business mailing address

1910 S STAPLEY DR STE 120
MESA AZ
85204-6676
US

V. Phone/Fax

Practice location:
  • Phone: 800-922-1873
  • Fax:
Mailing address:
  • Phone: 800-922-1873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: NELLIE IDARA SAMUEL
Title or Position: CO-OWNER
Credential: DNP
Phone: 800-922-1873