MEDICARE: MIRACLE HOME HEALTH OF WISCONSIN 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	251E00000X	Home Health Agency	1174	WI

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	:	1851667703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE HOME HEALTH OF WISCONSIN INC

Provider Business Mailing Address
First Line	:	7545 N PORT WASHINGTON RD STE 3
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-3422
Country	:	US
Telephone Number	:	414-915-0838
Fax Number	:	414-797-4544

Provider Business Practice Location Address
First Line	:	7545 N PORT WASHINGTON RD STE 3
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-3422
Country	:	US
Telephone Number	:	414-797-2254
Fax Number	:	888-910-5128

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	MS. ARKADIY KOPSHTEYN
Credential	:	MBA
Telephone Number	:	414-797-2254

Provider Enumeration Date	:	03/26/2012
Last Update Date	:	10/24/2023

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