Organization
MIRA VITA METAMOPHOSIS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANGELA MARIE DEROSA DO (OWNER)
(480) 619-4097
Entity
Organization
Contact information
Practice address
5620 W THUNDERBIRD RD STE H2, GLENDALE, AZ 85306-4653
(480) 407-9007
(833) 817-6790
Mailing address
5620 W THUNDERBIRD RD STE H2, GLENDALE, AZ 85306-4653
(480) 407-9007
(833) 817-6790
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
4223
AZ
207R00000X
Internal Medicine Physician
—
—
Other
Enumeration date
11/24/2014
Last updated
01/30/2020
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