Healthcare Provider Details

I. General information

NPI: 1720891674
Provider Name (Legal Business Name): METRO MG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5408 W FULLERTON AVE
CHICAGO IL
60639
US

IV. Provider business mailing address

5408 W FULLERTON AVE
CHICAGO IL
60639
US

V. Phone/Fax

Practice location:
  • Phone: 786-301-4903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JOSE AYALA
Title or Position: OWNER
Credential: MD
Phone: 786-301-4903