MEDICARE: MIRACLE HANDS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1043443781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE HANDS LLC

Provider Business Mailing Address
First Line	:	1839 COCHRAN PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205
Country	:	US
Telephone Number	:	704-605-2178
Fax Number	:

Provider Business Practice Location Address
First Line	:	1839 COCHRAN PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-3019
Country	:	US
Telephone Number	:	704-605-2178
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ERVIN DEXTER BLAKNEY II
Credential	:
Telephone Number	:	704-605-2178

Provider Enumeration Date	:	08/28/2009
Last Update Date	:	08/28/2009

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Directions to “MIRACLE HANDS LLC ” Practice Location

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