Healthcare Provider Details

I. General information

NPI: 1952088205
Provider Name (Legal Business Name): MIRACLE CARE DMEPOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 10/14/2023
Certification Date: 10/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 JEFFERSON ST N
WADENA MN
56482-1371
US

IV. Provider business mailing address

204 JEFFERSON ST N
WADENA MN
56482-1371
US

V. Phone/Fax

Practice location:
  • Phone: 612-688-7661
  • Fax: 612-688-7672
Mailing address:
  • Phone: 612-688-7661
  • Fax: 612-688-7672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JATTY D. ZONDO
Title or Position: CEO
Credential:
Phone: 612-688-7661