Healthcare Provider Details

I. General information

NPI: 1407402316
Provider Name (Legal Business Name): NEXT LEVEL VITALITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 W BRAHMAN BLVD
SAN TAN VALLEY AZ
85143-4852
US

IV. Provider business mailing address

26 W BRAHMAN BLVD
SAN TAN VALLEY AZ
85143-4852
US

V. Phone/Fax

Practice location:
  • Phone: 619-366-1546
  • Fax:
Mailing address:
  • Phone: 619-366-1546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TIA ROSS
Title or Position: OWNER
Credential:
Phone: 619-366-1546