Provider Demographics
NPI:1093110439
Name:FANNIE'S DIVINE MIRACLES,LLC
Entity Type:Organization
Organization Name:FANNIE'S DIVINE MIRACLES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:CAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-729-0009
Mailing Address - Street 1:1100 HOLLADAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2232
Mailing Address - Country:US
Mailing Address - Phone:757-729-0009
Mailing Address - Fax:757-966-5334
Practice Address - Street 1:1100 HOLLADAY ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2232
Practice Address - Country:US
Practice Address - Phone:757-729-0009
Practice Address - Fax:757-966-5334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FANNIE'S DIVINE MIRACLES,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1956320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities