Healthcare Provider Details

I. General information

NPI: 1881451326
Provider Name (Legal Business Name): MIRACLE GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 DARST AVE
DAYTON OH
45403-3106
US

IV. Provider business mailing address

1828 DARST AVE
DAYTON OH
45403-3106
US

V. Phone/Fax

Practice location:
  • Phone: 307-629-1722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: BATACHOKA NTIZIMIRA
Title or Position: OWNER
Credential:
Phone: 307-629-1722