Healthcare Provider Details

I. General information

NPI: 1336767516
Provider Name (Legal Business Name): VITAL HEALTHCARE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4338 W THOMAS RD # U1
PHOENIX AZ
85031-3878
US

IV. Provider business mailing address

4338 W THOMAS RD # U1
PHOENIX AZ
85031-3878
US

V. Phone/Fax

Practice location:
  • Phone: 775-335-7450
  • Fax:
Mailing address:
  • Phone: 775-335-7450
  • Fax: 602-825-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THEOPHILUS AKOH
Title or Position: MANAGING PARTNER
Credential: NP
Phone: 775-335-7450