Healthcare Provider Details

I. General information

NPI: 1669760203
Provider Name (Legal Business Name): VITALITY INTERNAL MEDICINE - TEMPE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4653 S LAKESHORE DR STE 2
TEMPE AZ
85282-7161
US

IV. Provider business mailing address

5509 E FRIESS DR
SCOTTSDALE AZ
85254-2966
US

V. Phone/Fax

Practice location:
  • Phone: 480-456-8981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number37616
License Number StateAZ

VIII. Authorized Official

Name: DR. CHARLES BENJAMIN EVANS II
Title or Position: OWNER
Credential: M.D.
Phone: 602-791-9112