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General NPI Number Information
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NPI Number | 1134550825
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Entity Type | Organization
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Legal Business Name | VITAL4MEN CHANDLER PLLC
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Dates
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Enumeration Date | 12/05/2013
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Last Update Date | 01/03/2014
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Provider Practice Location Address
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Address Line | 655 S DOBSON RD BLDG. B SUITE #216
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City | CHANDLER
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State | AZ
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Zip | 85224-5667
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Country | US
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Telephone | 623-399-8606
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Fax | 623-399-9958
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Provider Business Mailing Address
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Address Line | 7707 W DEER VALLEY RD STE 115
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City | PEORIA
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State | AZ
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Zip | 85382-2101
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Country | US
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Telephone | 623-399-8606
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Fax | 623-399-9958
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Authorized Official
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Title or Position | MEMBER
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Name | KEVIN WRAY
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Credential |
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Telephone | 623-399-8606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 15568
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License Number State | AZ
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