Healthcare Provider Details

I. General information

NPI: 1144038035
Provider Name (Legal Business Name): VITALIS VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 N 2ND ST STE 401
PHOENIX AZ
85012-2371
US

IV. Provider business mailing address

PO BOX 2253
PHOENIX AZ
85002-2253
US

V. Phone/Fax

Practice location:
  • Phone: 602-606-9619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CHRISTOPHER MENDIAS
Title or Position: MEMBER
Credential: PHD
Phone: 602-606-9619