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General NPI Number Information
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NPI Number | 1780982561
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Entity Type | Organization
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Legal Business Name | MEN'S VITALITY & PERFORMANCE
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Dates
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Enumeration Date | 03/03/2011
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Last Update Date | 03/03/2011
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Provider Practice Location Address
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Address Line | 4626 E SHEA BLVD SUITE C230
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City | PHOENIX
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State | AZ
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Zip | 85028-3071
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Country | US
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Telephone | 602-314-5119
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Fax | 602-368-4071
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Provider Business Mailing Address
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Address Line | 4626 E SHEA BLVD SUITE 230
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City | PHOENIX
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State | AZ
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Zip | 85028-3071
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Country | US
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Telephone | 602-314-5119
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Fax | 602-368-4071
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Authorized Official
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Title or Position | OWNER
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Name | JOHN RISI
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Credential |
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Telephone | 602-314-5119
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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 | 2830
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License Number State | AZ
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