Provider Demographics
NPI:1407200868
Name:VITALITY INTERNAL MEDICINE - PHOENIX PLLC
Entity Type:Organization
Organization Name:VITALITY INTERNAL MEDICINE - PHOENIX PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:602-791-9112
Mailing Address - Street 1:8776 E SHEA BLVD
Mailing Address - Street 2:STE B3A-129
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4643 N 12TH ST
Practice Address - Street 2:STE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4006
Practice Address - Country:US
Practice Address - Phone:602-626-8986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37616261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care