=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265152888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAZO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2022
-----------------------------------------------------
Last Update Date | 09/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 888 N 1ST AVE, # 419
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85003-1681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-281-0373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 N 1ST AVE APT 419
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85003-1681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-281-0373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MBA STEPHEN AZODEH
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 602-281-0373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------