Provider Demographics
NPI:1396190724
Name:VITAL4MEN, PLLC
Entity Type:Organization
Organization Name:VITAL4MEN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:DISHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-218-1515
Mailing Address - Street 1:7707 W DEER VALLEY RD
Mailing Address - Street 2:STE 115
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2101
Mailing Address - Country:US
Mailing Address - Phone:623-218-1515
Mailing Address - Fax:623-566-0019
Practice Address - Street 1:655 S DOBSON RD
Practice Address - Street 2:B216
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5667
Practice Address - Country:US
Practice Address - Phone:480-223-1312
Practice Address - Fax:480-773-7902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty