Healthcare Provider Details

I. General information

NPI: 1093043531
Provider Name (Legal Business Name): VMG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S STAPLEY DR SUITE 111
MESA AZ
85204-5059
US

IV. Provider business mailing address

212 W SUPERSTITION BLVD SUITE 101
APACHE JUNCTION AZ
85120-4127
US

V. Phone/Fax

Practice location:
  • Phone: 480-398-1220
  • Fax: 480-983-1230
Mailing address:
  • Phone: 480-983-4200
  • Fax: 480-983-4317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number29241
License Number StateAZ

VIII. Authorized Official

Name: MS. SHANNON GRAY
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 480-983-4200