Healthcare Provider Details

I. General information

NPI: 1669122396
Provider Name (Legal Business Name): MIRACLE SOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6028 SURETY DR
EL PASO TX
79905-2018
US

IV. Provider business mailing address

1505 BLACKFOOT
EL PASO TX
79928-6019
US

V. Phone/Fax

Practice location:
  • Phone: 915-544-3500
  • Fax:
Mailing address:
  • Phone: 915-255-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number106602
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: