1134769946 NPI number — MIRACLE HOME CARE LLC

Table of content: VERONICA KVARTA BROHM D.O. (NPI 1699060921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134769946 NPI number — MIRACLE HOME CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACLE HOME CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134769946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29121 FARWELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48047-5336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29121 FARWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48047-5336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-396-2494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MIRACLE
Authorized Official First Name:
EKATERINA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
248-396-2494

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 802390195 . This is a "ID NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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