Provider Demographics
NPI:1437982998
Name:RADIANT MEN'S HEALTH CLUB
Entity type:Organization
Organization Name:RADIANT MEN'S HEALTH CLUB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:623-693-2198
Mailing Address - Street 1:6635 W HAPPY VALLEY RD STE A104
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5940 W UNION HILLS DR STE B100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1313
Practice Address - Country:US
Practice Address - Phone:480-219-7098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care