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General NPI Number Information
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NPI Number | 1932826906
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Entity Type | Organization
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Legal Business Name | A MIRACLE GROUP, LLC
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Dates
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Enumeration Date | 10/20/2022
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Last Update Date | 10/20/2022
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Provider Practice Location Address
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Address Line | 3706 WINCHESTER DR
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City | PORTSMOUTH
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State | VA
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Zip | 23707-4332
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Country | US
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Telephone | 757-675-8763
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Fax | 757-483-6525
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Provider Business Mailing Address
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Address Line | 4621 MALLARD CRES
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City | PORTSMOUTH
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State | VA
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Zip | 23703-2240
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Country | US
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Telephone | 757-675-8763
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Fax | 757-483-6525
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Authorized Official
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Title or Position | CEO
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Name | LISA OUTLAND
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Credential |
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Telephone | 757-675-8763
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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