Provider Demographics
NPI:1821492091
Name:VITAL MALE SCOTTSDALE LLC
Entity Type:Organization
Organization Name:VITAL MALE SCOTTSDALE LLC
Other - Org Name:THE VITAL MALE SCOTTSDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-998-4825
Mailing Address - Street 1:11000 N SCOTTSDALE RD
Mailing Address - Street 2:STE. 145
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6130
Mailing Address - Country:US
Mailing Address - Phone:480-998-4825
Mailing Address - Fax:480-219-5173
Practice Address - Street 1:11000 N SCOTTSDALE RD
Practice Address - Street 2:STE. 145
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6130
Practice Address - Country:US
Practice Address - Phone:480-998-4825
Practice Address - Fax:480-219-5173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MOTHERSHIP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ091121175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty