Healthcare Provider Details

I. General information

NPI: 1588780761
Provider Name (Legal Business Name): MRACLES RESIDENTIAL CARE LLC - JOHNSON HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E 79TH ST
KANSAS CITY MO
64131-1954
US

IV. Provider business mailing address

1301 E 79TH ST
KANSAS CITY MO
64131-1954
US

V. Phone/Fax

Practice location:
  • Phone: 816-521-8896
  • Fax: 816-437-7027
Mailing address:
  • Phone: 816-521-8896
  • Fax: 816-437-7027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. DEDREE RENEE CARLISLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 816-521-8896