| Mira Vita Metamophosis, Llc | |
|
5620 W Thunderbird Rd Ste H2 Glendale AZ 85306-4653 | |
| (480) 407-9007 | |
| (833) 817-6790 |
| Full Name | Mira Vita Metamophosis, Llc |
|---|---|
| Speciality | Internal Medicine |
| Location | 5620 W Thunderbird Rd Ste H2, Glendale, Arizona |
| Authorized Official Name and Position | Angela Marie Derosa (OWNER) |
| Authorized Official Contact | 4806194097 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Mira Vita Metamophosis, Llc 5620 W Thunderbird Rd Ste H2 Glendale AZ 85306-4653 Ph: (480) 407-9007 | Mira Vita Metamophosis, Llc 5620 W Thunderbird Rd Ste H2 Glendale AZ 85306-4653 Ph: (480) 407-9007 |
| NPI Number | 1073910873 |
|---|---|
| Provider Enumeration Date | 11/24/2014 |
| Last Update Date | 01/30/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1073910873 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 4223 (Arizona) | Primary |
| 207R00000X | Internal Medicine | (* (Not Available)) | Secondary |
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