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General NPI Number Information
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NPI Number | 1447932280
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Entity Type | Organization
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Legal Business Name | VIP IV & MEDICAL SPA, LLC
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Dates
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Enumeration Date | 08/02/2023
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Last Update Date | 01/11/2024
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Provider Practice Location Address
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Address Line | 1690 MCCULLOCH BLVD N STE 102
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-6560
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Country | US
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Telephone | 480-404-4896
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Fax | 480-400-1063
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Provider Business Mailing Address
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Address Line | 1747 LOS LAGOS DR
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-6625
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Country | US
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Telephone | 480-404-4896
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Fax | 480-400-1063
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Authorized Official
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Title or Position | OWNER, FAMILY NURSE PRACTITIONER
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Name | MS. KELLEY ROBIN FARLEY
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Credential | FNP-C
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Telephone | 480-404-4896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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