=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508455221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY & MIRACLE HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2021
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 WALTON RD
-----------------------------------------------------
City | OVERLAND
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63114-5805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-401-8028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 EARTH CITY PLZ STE 312
-----------------------------------------------------
City | EARTH CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63045-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-222-8130
-----------------------------------------------------
Fax | 314-492-0196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SANDRA JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-401-8028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------