Provider Demographics
NPI:1639443757
Name:VITAL4MEN LLC
Entity type:Organization
Organization Name:VITAL4MEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:DISHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-218-1515
Mailing Address - Street 1:7707 W DEER VALLEY RD
Mailing Address - Street 2:115
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2101
Mailing Address - Country:US
Mailing Address - Phone:623-218-1515
Mailing Address - Fax:
Practice Address - Street 1:7707 W DEER VALLEY RD
Practice Address - Street 2:115
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2101
Practice Address - Country:US
Practice Address - Phone:623-218-1515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty