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General NPI Number Information
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NPI Number | 1851676506
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Entity Type | Organization
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Legal Business Name | MIRACLE WORKERS C.L.A. LLC
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Dates
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Enumeration Date | 10/13/2011
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Last Update Date | 10/13/2011
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Provider Practice Location Address
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Address Line | 5 VINEYARD HAVEN DR
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City | POOLER
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State | GA
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Zip | 31322-8250
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Country | US
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Telephone | 912-247-8424
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7071
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City | SAVANNAH
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State | GA
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Zip | 31418-7071
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Country | US
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Telephone | 912-247-8424
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MELISSA GREEN
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Credential |
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Telephone | 912-247-8424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | PCH001449
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License Number State | GA
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