Healthcare Provider Details

I. General information

NPI: 1366094393
Provider Name (Legal Business Name): MAA WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3146 E WIER AVE RM 19
PHOENIX AZ
85040-2754
US

IV. Provider business mailing address

3146 E WIER AVE RM 19
PHOENIX AZ
85040-2754
US

V. Phone/Fax

Practice location:
  • Phone: 602-305-4719
  • Fax:
Mailing address:
  • Phone: 602-305-4719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2278G1100X
TaxonomyGeneral Care Certified Respiratory Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELA GRAGG
Title or Position: PRESIDENT
Credential: R.N.
Phone: 602-305-4719