Provider Demographics
NPI:1336500867
Name:VITALITY CLINICAL LABORATORIES PLLC
Entity type:Organization
Organization Name:VITALITY CLINICAL LABORATORIES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
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 1:8776 E SHEA BLVD
Mailing Address - Street 2:STE B3A-129
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6629
Mailing Address - Country:US
Mailing Address - Phone:602-791-9112
Mailing Address - Fax:855-431-7712
Practice Address - Street 1:4643 N 12TH ST
Practice Address - Street 2:STE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4006
Practice Address - Country:US
Practice Address - Phone:602-791-9112
Practice Address - Fax:855-431-7712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D2073405291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory