1609169465 NPI number — VITALITY AGE MANAGEMENT

Table of content: (NPI 1609169465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609169465 NPI number — VITALITY AGE MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY AGE MANAGEMENT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VITALITY INTERGRATIVE MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609169465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6890 E SUNRISE DR
Provider Second Line Business Mailing Address:
SUITE 120-266
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85750-0738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
180-030-0846
Provider Business Mailing Address Fax Number:
186-656-7533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1845 W ORANGE GROVE RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85704-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-300-8464
Provider Business Practice Location Address Fax Number:
966-567-5331
Provider Enumeration Date:
05/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TIPIRNENI
Authorized Official First Name:
MAHESH
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
18003008464

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  34480 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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