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General NPI Number Information
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NPI Number | 1245041813
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Entity Type | Organization
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Legal Business Name | BELLA VITA WELLNESS LLC
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Dates
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Enumeration Date | 01/14/2025
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Last Update Date | 04/24/2025
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Provider Practice Location Address
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Address Line | 8812 E PALM LN
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City | MESA
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State | AZ
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Zip | 85207-9113
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Country | US
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Telephone | 480-269-7906
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1503
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-1833
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | CODY KNUDSON
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Credential |
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Telephone | 480-269-7906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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