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NPI Code Detail

MEDICARE: VITALIS WELLNESS CENTER OF PHOENIX, AZ PC

MEDICARE: VITALIS WELLNESS CENTER OF PHOENIX, AZ PC
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
12084P0800XPsychiatry Physician
22084P0804XChild & Adolescent Psychiatry Physician
32084P0301XBrain Injury Medicine (Psychiatry & Neurology) Physician

General Provider Information

NPI Number : 1497421101
Entity Type Code : Organization
Provider Name (Legal Business Name) : VITALIS WELLNESS CENTER OF PHOENIX, AZ PC
Provider Business Mailing Address
First Line : 1910 S STAPLEY DR STE 120
Second Line :
City : MESA
State : AZ
Zip : 85204-6676
Country : US
Telephone Number : 800-922-1873
Fax Number :
Provider Business Practice Location Address
First Line : 1910 S STAPLEY DR STE 120
Second Line :
City : MESA
State : AZ
Zip : 85204-6676
Country : US
Telephone Number : 800-922-1873
Fax Number :
Authorized Official
Title or Position : CO-OWNER
Name : NELLIE IDARA SAMUEL
Credential : DNP
Telephone Number : 800-922-1873
Provider Enumeration Date : 08/22/2021
Last Update Date : 07/19/2024

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Directions to “VITALIS WELLNESS CENTER OF PHOENIX, AZ PC ” Practice Location

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