Healthcare Provider Details

I. General information

NPI: 1639773054
Provider Name (Legal Business Name): MIRACLE KIDS SUCCESS ACADEMY OF TRUMANN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BALCOM LN
TRUMANN AR
72472-9502
US

IV. Provider business mailing address

3127 SOUTHWEST DR STE A
JONESBORO AR
72404-8404
US

V. Phone/Fax

Practice location:
  • Phone: 870-418-1000
  • Fax:
Mailing address:
  • Phone: 870-336-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELLY A KELLER
Title or Position: CEO
Credential:
Phone: 870-336-8100