Healthcare Provider Details

I. General information

NPI: 1396623807
Provider Name (Legal Business Name): MA MIRA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 ADAMS ST STE H
STEVENSON AL
35772-3790
US

IV. Provider business mailing address

104 ADAMS ST STE H
STEVENSON AL
35772-3790
US

V. Phone/Fax

Practice location:
  • Phone: 423-774-4191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SARIKA P DESAI
Title or Position: OWNER
Credential:
Phone: 432-774-4191