Healthcare Provider Details

I. General information

NPI: 1700491552
Provider Name (Legal Business Name): MIRACLE COMMUNITY BEHAVIORAL CENTER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15660 SW 72ND ST
MIAMI FL
33193-1923
US

IV. Provider business mailing address

15660 SW 72ND ST
MIAMI FL
33193-1923
US

V. Phone/Fax

Practice location:
  • Phone: 786-697-1150
  • Fax:
Mailing address:
  • Phone: 786-697-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRISAIDA DUARTE
Title or Position: CEO
Credential:
Phone: 786-697-1150