MEDICARE: MIRACLEO OF LOVE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1447783956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLEO OF LOVE, INC.

Provider Business Mailing Address
First Line	:	741 W COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7343
Country	:	US
Telephone Number	:	407-843-1760
Fax Number	:	407-843-1767

Provider Business Practice Location Address
First Line	:	741 W COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7343
Country	:	US
Telephone Number	:	407-843-1760
Fax Number	:	407-843-1767

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. ANGUS BRADSHAW JR.
Credential	:
Telephone Number	:	407-843-1760

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	04/11/2017

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