Provider Demographics
NPI:1366094393
Name:MAA WELLNESS CENTER
Entity type:Organization
Organization Name:MAA WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:602-305-4719
Mailing Address - Street 1:3146 E WIER AVE
Mailing Address - Street 2:RM 19
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-2754
Mailing Address - Country:US
Mailing Address - Phone:602-305-4719
Mailing Address - Fax:
Practice Address - Street 1:3146 E WIER AVE RM 19
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-2754
Practice Address - Country:US
Practice Address - Phone:602-305-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-10
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No2278G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGeneral CareGroup - Multi-Specialty