Provider Demographics
NPI:1780982561
Name:MEN'S VITALITY & PERFORMANCE
Entity type:Organization
Organization Name:MEN'S VITALITY & PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RISI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-314-5119
Mailing Address - Street 1:4626 E SHEA BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3071
Mailing Address - Country:US
Mailing Address - Phone:602-314-5119
Mailing Address - Fax:602-368-4071
Practice Address - Street 1:4626 E SHEA BLVD
Practice Address - Street 2:SUITE C230
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3071
Practice Address - Country:US
Practice Address - Phone:602-314-5119
Practice Address - Fax:602-368-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty