Provider Demographics
NPI:1497421101
Name:VITALIS WELLNESS CENTER OF PHOENIX
Entity Type:Organization
Organization Name:VITALIS WELLNESS CENTER OF PHOENIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:INIMBOM
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-765-8224
Mailing Address - Street 1:333 N DOBSON RD STE 5-173
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4412
Mailing Address - Country:US
Mailing Address - Phone:800-922-1873
Mailing Address - Fax:
Practice Address - Street 1:333 N DOBSON RD STE 5-173
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4412
Practice Address - Country:US
Practice Address - Phone:800-922-1873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0301XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBrain Injury MedicineGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty