Healthcare Provider Details

I. General information

NPI: 1619323045
Provider Name (Legal Business Name): VITAL4MEN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 E BASELINE RD STE 111
MESA AZ
85206-4412
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 480-825-7615
  • Fax: 480-248-7658
Mailing address:
  • Phone: 623-218-1515
  • Fax: 623-566-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TODD DISHON
Title or Position: PARTNER/MEMBER
Credential:
Phone: 623-218-1515