Healthcare Provider Details

I. General information

NPI: 1992082788
Provider Name (Legal Business Name): MIRACLES NETWORK AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 SUGG PL
DYERSBURG TN
38024-3052
US

IV. Provider business mailing address

615 SUGG PL
DYERSBURG TN
38024-3052
US

V. Phone/Fax

Practice location:
  • Phone: 731-285-6499
  • Fax:
Mailing address:
  • Phone: 731-285-6499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number0298258
License Number StateTN

VIII. Authorized Official

Name: ANDREA LO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 731-285-6499