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General NPI Number Information
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NPI Number | 1255835997
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Entity Type | Organization
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Legal Business Name | MIRACLE ON 29TH STREET
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Dates
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Enumeration Date | 03/19/2018
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Last Update Date | 09/12/2025
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Provider Practice Location Address
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Address Line | 18210 N 29TH ST
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City | PHOENIX
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State | AZ
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Zip | 85032-1103
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Country | US
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Telephone | 480-302-1101
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Fax |
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Provider Business Mailing Address
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Address Line | 18210 N 29TH ST
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City | PHOENIX
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State | AZ
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Zip | 85032-1103
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Country | US
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Telephone | 480-302-1101
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. TROY BERKLEY
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Credential |
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Telephone | 480-302-1101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | AL10509H
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License Number State | AZ
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