Provider Demographics
NPI:1336436690
Name:VITALITY INTERNAL MEDICINE - GLENDALE LLC
Entity Type:Organization
Organization Name:VITALITY INTERNAL MEDICINE - GLENDALE LLC
Other - Org Name:MENS VITALITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:602-791-9112
Mailing Address - Street 1:5509 E FRIESS DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18205 N 51ST AVE STE 129
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1492
Practice Address - Country:US
Practice Address - Phone:623-398-8554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37616261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care