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General NPI Number Information
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NPI Number | 1295768075
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Entity Type | Organization
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Legal Business Name | MIRACLE OUTLOOK FAMILY SERVICES
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Dates
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Enumeration Date | 07/08/2006
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Last Update Date | 04/28/2017
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Provider Practice Location Address
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Address Line | 2404 FERRAND ST SUITE 21
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City | MONROE
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State | LA
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Zip | 71201-3234
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Country | US
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Telephone | 318-324-0048
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Fax | 318-324-0199
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Provider Business Mailing Address
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Address Line | 2404 FERRAND ST SUITE 21
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City | MONROE
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State | LA
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Zip | 71201-3234
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Country | US
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Telephone | 318-324-0048
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Fax | 318-324-0199
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Authorized Official
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Title or Position | OWNER
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Name | MRS. REGINA L JACKSON
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Credential |
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Telephone | 318-324-0048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 2203781289
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 10851
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License Number State | LA
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