Healthcare Provider Details

I. General information

NPI: 1558654665
Provider Name (Legal Business Name): WONDERFUL MOVING MIRACLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6657 CARRIAGE LANE AVE NE
CANTON OH
44721-2580
US

IV. Provider business mailing address

6657 CARRIAGE LANE AVE NE
CANTON OH
44721-2580
US

V. Phone/Fax

Practice location:
  • Phone: 330-354-4844
  • Fax: 330-494-3247
Mailing address:
  • Phone: 330-354-4844
  • Fax: 330-494-3247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number1523810002
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number1523810002
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number1523810002
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1523810002
License Number StateOH

VIII. Authorized Official

Name: MRS. GLENDA MARSHALL
Title or Position: CEO
Credential:
Phone: 330-354-4844