MEDICARE: BELLA VITA WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0401X	Addiction Medicine (Family Medicine) Physician
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1245041813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLA VITA WELLNESS LLC

Provider Business Mailing Address
First Line	:	PO BOX 1503
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-1833
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8812 E PALM LN
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-9113
Country	:	US
Telephone Number	:	480-269-7906
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	CODY KNUDSON
Credential	:
Telephone Number	:	480-269-7906

Provider Enumeration Date	:	01/14/2025
Last Update Date	:	04/24/2025

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Directions to “BELLA VITA WELLNESS LLC ” Practice Location

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