MEDICARE: MIRACLE KIDS LLC

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	225X00000X	Occupational Therapist	OT002706	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568678217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE KIDS LLC

Provider Business Mailing Address
First Line	:	1442 DRESDEN DR NE UNIT C258
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3590
Country	:	US
Telephone Number	:	678-779-3599
Fax Number	:	678-922-1235

Provider Business Practice Location Address
First Line	:	1442 DRESDEN DR NE UNIT C258
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3590
Country	:	US
Telephone Number	:	678-779-3599
Fax Number	:	678-922-1235

Authorized Official
Title or Position	:	OWNER
Name	:	MS. RABINDER KAUR ROY
Credential	:	OTRL
Telephone Number	:	678-799-3599

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	03/03/2017

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Directions to “MIRACLE KIDS LLC ” Practice Location

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