Provider Demographics
NPI:1609169465
Name:VITALITY AGE MANAGEMENT
Entity Type:Organization
Organization Name:VITALITY AGE MANAGEMENT
Other - Org Name:VITALITY INTERGRATIVE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHESH
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPIRNENI
Authorized Official - Suffix:
Authorized Official - Credentials:M
Authorized Official - Phone:1800-300-8464
Mailing Address - Street 1:6890 E SUNRISE DR
Mailing Address - Street 2:SUITE 120-266
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-0738
Mailing Address - Country:US
Mailing Address - Phone:180-030-0846
Mailing Address - Fax:186-656-7533
Practice Address - Street 1:1845 W ORANGE GROVE RD
Practice Address - Street 2:SUITE 115
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1134
Practice Address - Country:US
Practice Address - Phone:800-300-8464
Practice Address - Fax:966-567-5331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty