Healthcare Provider Details

I. General information

NPI: 1568782308
Provider Name (Legal Business Name): MEN'S VITALITY CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

12878 N 119TH ST
SCOTTSDALE AZ
85259-2736
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 Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: NIKKI MIGLORE
Title or Position: OWNER/MBR
Credential: DC
Phone: 480-229-1986