Provider Demographics
NPI:1073910873
Name:MIRA VITA METAMOPHOSIS, LLC
Entity Type:Organization
Organization Name:MIRA VITA METAMOPHOSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-619-4097
Mailing Address - Street 1:5620 W THUNDERBIRD RD STE H2
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4653
Mailing Address - Country:US
Mailing Address - Phone:480-407-9007
Mailing Address - Fax:833-817-6790
Practice Address - Street 1:5620 W THUNDERBIRD RD STE H2
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4653
Practice Address - Country:US
Practice Address - Phone:480-407-9007
Practice Address - Fax:833-817-6790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4223207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty