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General NPI Number Information
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NPI Number | 1447767181
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Entity Type | Organization
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Legal Business Name | RESTORE VITALITY CENTER
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Dates
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Enumeration Date | 01/03/2018
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Last Update Date | 01/03/2018
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Provider Practice Location Address
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Address Line | 8133 W HEATHERBRAE DR
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City | PHOENIX
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State | AZ
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Zip | 85033-2336
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Country | US
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Telephone | 602-814-2559
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Fax |
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Provider Business Mailing Address
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Address Line | 8133 W HEATHERBRAE DR
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City | PHOENIX
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State | AZ
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Zip | 85033-2336
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Country | US
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Telephone | 602-814-2559
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Fax |
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | MR. MICHAEL NELSON
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Credential |
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Telephone | 602-814-2559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204R00000X
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Taxonomy Name | Electrodiagnostic Medicine Physician
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License Number |
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 2081N0008X
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Taxonomy Name | Neuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State | AZ
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Taxonomy #5
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number |
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License Number State | AZ
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Taxonomy #6
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State | AZ
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