Healthcare Provider Details

I. General information

NPI: 1306020615
Provider Name (Legal Business Name): MIRACLE OUTLOOK FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 FERRAND ST SUITE 21
MONROE LA
71201-4954
US

IV. Provider business mailing address

2404 FERRAND ST SUITE 21
MONROE LA
71201-4954
US

V. Phone/Fax

Practice location:
  • Phone: 318-324-0048
  • Fax:
Mailing address:
  • Phone: 318-324-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number10851
License Number StateLA

VIII. Authorized Official

Name: RGINA JACKSON
Title or Position: OWNER
Credential:
Phone: 318-324-0048