MEDICARE: MIRACLE GROUP HOME 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	374U00000X	Home Health Aide
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1881451326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACLE GROUP HOME LLC

Provider Business Mailing Address
First Line	:	1828 DARST AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-3106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1828 DARST AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-3106
Country	:	US
Telephone Number	:	307-629-1722
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BATACHOKA NTIZIMIRA
Credential	:
Telephone Number	:	307-629-1722

Provider Enumeration Date	:	03/01/2024
Last Update Date	:	03/01/2024

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