Healthcare Provider Details

I. General information

NPI: 1043630924
Provider Name (Legal Business Name): MIRACLES1ST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5128 4TH ST NE
COLUMBIA HEIGHTS MN
55421-2874
US

IV. Provider business mailing address

5128 4TH ST NE
COLUMBIA HEIGHTS MN
55421-2874
US

V. Phone/Fax

Practice location:
  • Phone: 763-528-5431
  • Fax:
Mailing address:
  • Phone: 763-528-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: PATRICE WYNNE-FINLEY
Title or Position: GOVERNING BODY
Credential:
Phone: 753-528-5431