=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326465584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWER HOUSE MIRACLE CENTER MINISTRIES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2014
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12373 CADLEY CIR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32219-1860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-894-6828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12373 CADLEY CIR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32219-1860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-894-6828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. MELISSA A WADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-894-6828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12135
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------