Provider Demographics
NPI:1134550825
Name:VITAL4MEN CHANDLER PLLC
Entity type:Organization
Organization Name:VITAL4MEN CHANDLER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-399-8606
Mailing Address - Street 1:7707 W DEER VALLEY RD
Mailing Address - Street 2:STE 115
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2101
Mailing Address - Country:US
Mailing Address - Phone:623-399-8606
Mailing Address - Fax:623-399-9958
Practice Address - Street 1:655 S DOBSON RD
Practice Address - Street 2:BLDG. B SUITE #216
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5667
Practice Address - Country:US
Practice Address - Phone:623-399-8606
Practice Address - Fax:623-399-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15568207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty