Healthcare Provider Details

I. General information

NPI: 1720438161
Provider Name (Legal Business Name): VITAL PHYSICIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 ROSE LN
WICKENBURG AZ
85390-1447
US

IV. Provider business mailing address

9393 N 90TH ST STE 102-557
SCOTTSDALE AZ
85258-5040
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51880
License Number StateAZ

VIII. Authorized Official

Name: JON J SKALECKI
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 401-241-7723