=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114233715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRACLE HEALTH CARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2010
-----------------------------------------------------
Last Update Date | 08/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 396 PIEDMONT AVE NE UNIT 4013
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-705-8075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 396 PIEDMONT AVE NE UNIT 4013
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-705-8075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. XAVIER YOUNG
-----------------------------------------------------
Credential | B.S.
-----------------------------------------------------
Telephone | 704-315-3895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------