MEDICARE: MRACLES RESIDENTIAL CARE LLC - JOHNSON HOUSE

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

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	:	1588780761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MRACLES RESIDENTIAL CARE LLC - JOHNSON HOUSE

Provider Business Mailing Address
First Line	:	1301 E 79TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64131-1954
Country	:	US
Telephone Number	:	816-521-8896
Fax Number	:	816-437-7027

Provider Business Practice Location Address
First Line	:	1301 E 79TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64131-1954
Country	:	US
Telephone Number	:	816-521-8896
Fax Number	:	816-437-7027

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. DEDREE RENEE CARLISLE
Credential	:
Telephone Number	:	816-521-8896

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	10/16/2013

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