Provider Demographics
NPI:1093984171
Name:MMGL, LLC
Entity Type:Organization
Organization Name:MMGL, LLC
Other - Org Name:FIVE STAR MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:MANUELA
Authorized Official - Last Name:GONZALEZ-LANDESTOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-275-4415
Mailing Address - Street 1:2175 N. ALMA SCHOOL RD.
Mailing Address - Street 2:SUITE A- 104
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:480-275-4415
Mailing Address - Fax:480-275-4577
Practice Address - Street 1:2175 N. ALMA SCHOOL RD.
Practice Address - Street 2:SUITE A- 104
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-275-4415
Practice Address - Fax:480-275-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2020-02-19
Deactivation Date:2017-05-03
Deactivation Code:
Reactivation Date:2020-02-19
Provider Licenses
StateLicense IDTaxonomies
AZ29719305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0744170OtherAZ BC/BS
AZZ78260OtherMEDICARE GROUP NUMBER
AZ632697Medicaid
AZZ78262Medicare PIN
AZ0744170OtherAZ BC/BS