Provider Demographics
NPI:1841697091
Name:THE ANTI-AGING SPOT LLC
Entity type:Organization
Organization Name:THE ANTI-AGING SPOT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:480-599-8370
Mailing Address - Street 1:1753 E BROADWAY RD STE 101-190
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1580
Mailing Address - Country:US
Mailing Address - Phone:602-321-7578
Mailing Address - Fax:
Practice Address - Street 1:4845 E THUNDERBIRD RD
Practice Address - Street 2:STE 4
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-3556
Practice Address - Country:US
Practice Address - Phone:480-599-8370
Practice Address - Fax:480-436-6747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14-1470175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty