Healthcare Provider Details

I. General information

NPI: 1447767181
Provider Name (Legal Business Name): RESTORE VITALITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8133 W HEATHERBRAE DR
PHOENIX AZ
85033-2336
US

IV. Provider business mailing address

8133 W HEATHERBRAE DR
PHOENIX AZ
85033-2336
US

V. Phone/Fax

Practice location:
  • Phone: 602-814-2559
  • Fax:
Mailing address:
  • Phone: 602-814-2559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. MICHAEL NELSON
Title or Position: OWNER/MEMBER
Credential:
Phone: 602-814-2559