Provider Demographics
NPI:1235815333
Name:VITAL WELLNESS CENTER LLC
Entity type:Organization
Organization Name:VITAL WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KARINE
Authorized Official - Middle Name:
Authorized Official - Last Name:YAZIDZHYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-635-4192
Mailing Address - Street 1:3150 N 24TH ST STE A202
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7354
Mailing Address - Country:US
Mailing Address - Phone:602-635-4192
Mailing Address - Fax:602-635-4193
Practice Address - Street 1:3150 N 24TH ST STE A202
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7354
Practice Address - Country:US
Practice Address - Phone:602-635-4192
Practice Address - Fax:602-635-4193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-23
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty