MEDICARE: MIRACLE MILE MEDICAL CENTER, 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	282N00000X	General Acute Care Hospital	930000143	CA

General Provider Information

NPI Number	:	1184773202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE MILE MEDICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 17358
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91416-7358
Country	:	US
Telephone Number	:	323-930-1040
Fax Number	:	323-937-0525

Provider Business Practice Location Address
First Line	:	6000 SAN VICENTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4404
Country	:	US
Telephone Number	:	323-930-1040
Fax Number	:	323-937-0525

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. JAMES K. THEIRING
Credential	:
Telephone Number	:	323-556-3942

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	06/30/2008

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