Healthcare Provider Details

I. General information

NPI: 1952653255
Provider Name (Legal Business Name): TRIVITA PROFESSIONAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16100 N GREENWAY HAYDEN LOOP G-100
SCOTTSDALE AZ
85260-1652
US

IV. Provider business mailing address

16100 N GREENWAY HAYDEN LOOP G-100
SCOTTSDALE AZ
85260-1652
US

V. Phone/Fax

Practice location:
  • Phone: 480-337-4140
  • Fax:
Mailing address:
  • Phone: 480-337-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL JOHN BERNITT
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-337-4148