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General NPI Number Information
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NPI Number | 1083232102
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Entity Type | Organization
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Legal Business Name | MODE - MIRACLES OCCUR DAYS ENRICHED A NON-PROFIT CORPORATION
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Dates
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Enumeration Date | 07/07/2020
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Last Update Date | 11/11/2021
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Provider Practice Location Address
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Address Line | 50 BAKER BLVD STE 5A
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City | FAIRLAWN
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State | OH
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Zip | 44333-3603
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Country | US
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Telephone | 330-388-5757
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Fax |
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Provider Business Mailing Address
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Address Line | 50 BAKER BLVD STE 5A
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City | FAIRLAWN
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State | OH
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Zip | 44333-3603
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Country | US
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Telephone | 330-388-5757
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Fax | 330-294-1581
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. LISA LENORA PETRARCA-GAMIDO
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Credential | LICDC, SWA
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Telephone | 330-388-5757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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