Healthcare Provider Details

I. General information

NPI: 1518663731
Provider Name (Legal Business Name): MIRACL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W 10TH ST # US
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1050 W 10TH ST # US
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-8181
  • Fax: 314-747-1429
Mailing address:
  • Phone: 314-454-8181
  • Fax: 314-747-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CATHY EGHIGIAN
Title or Position: SR. DIRECTOR, MANAGED CARE
Credential:
Phone: 618-791-0975