Provider Demographics
NPI:1053505941
Name:TOTAL MIRACLE KIDS,INC.
Entity Type:Organization
Organization Name:TOTAL MIRACLE KIDS,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-854-8399
Mailing Address - Street 1:208 KAITLYN LN
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-3951
Mailing Address - Country:US
Mailing Address - Phone:704-854-4942
Mailing Address - Fax:704-854-8410
Practice Address - Street 1:212 W 2ND AVE STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4055
Practice Address - Country:US
Practice Address - Phone:704-854-8399
Practice Address - Fax:704-854-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300955BMedicaid