1154675403 NPI number — MIRACLE HOUSES, INCORPORATED

Table of content: (NPI 1154675403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154675403 NPI number — MIRACLE HOUSES, INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACLE HOUSES, INCORPORATED
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:
1154675403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
544 MULBERRY ST STE 613
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31201-6324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-315-3895
Provider Business Mailing Address Fax Number:
704-535-4476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 18TH ST NW
Provider Second Line Business Practice Location Address:
UNIT 10212
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-315-3895
Provider Business Practice Location Address Fax Number:
704-535-4476
Provider Enumeration Date:
11/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CAMP
Authorized Official First Name:
PATSY
Authorized Official Middle Name:
YOUNG
Authorized Official Title or Position:
EXECUTIVE DIRECTOR/VICE PRESIDENT
Authorized Official Telephone Number:
704-369-1445

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1861796179 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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