Healthcare Provider Details

I. General information

NPI: 1669734349
Provider Name (Legal Business Name): MIRACLE CHILREN INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18908 MANGIN AVE
SAINT ALBANS NY
11412-2320
US

IV. Provider business mailing address

18908 MANGIN AVE
SAINT ALBANS NY
11412-2320
US

V. Phone/Fax

Practice location:
  • Phone: 347-858-6537
  • Fax:
Mailing address:
  • Phone: 347-858-6537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number174847021
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number174847021
License Number StateNY

VIII. Authorized Official

Name: LORNA HOSANG
Title or Position: DIRECTOR
Credential: MS. ED.
Phone: 347-858-6537