Healthcare Provider Details

I. General information

NPI: 1518546548
Provider Name (Legal Business Name): VESTRA LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11036 N 23RD AVE STE 8
PHOENIX AZ
85029-4800
US

IV. Provider business mailing address

11036 N 23RD AVE STE 8
PHOENIX AZ
85029-4800
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-1390
  • Fax:
Mailing address:
  • Phone: 623-334-1390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW NAGELBUSH
Title or Position: CEO
Credential:
Phone: 623-205-3445