Provider Demographics
NPI:1952653255
Name:TRIVITA PROFESSIONAL WELLNESS
Entity Type:Organization
Organization Name:TRIVITA PROFESSIONAL WELLNESS
Other - Org Name:TRIVITA WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BERNITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-337-4148
Mailing Address - Street 1:16100 N GREENWAY HAYDEN LOOP
Mailing Address - Street 2:G-100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1652
Mailing Address - Country:US
Mailing Address - Phone:480-337-4140
Mailing Address - Fax:
Practice Address - Street 1:16100 N GREENWAY HAYDEN LOOP
Practice Address - Street 2:G-100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1652
Practice Address - Country:US
Practice Address - Phone:480-337-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty