Provider Demographics
NPI:1114233715
Name:MIRACLE HEALTH CARE SERVICES
Entity Type:Organization
Organization Name:MIRACLE HEALTH CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:XAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:704-315-3895
Mailing Address - Street 1:396 PIEDMONT AVE NE
Mailing Address - Street 2:UNIT 4013
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-3400
Mailing Address - Country:US
Mailing Address - Phone:678-705-8075
Mailing Address - Fax:
Practice Address - Street 1:396 PIEDMONT AVE NE
Practice Address - Street 2:UNIT 4013
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-3400
Practice Address - Country:US
Practice Address - Phone:678-705-8075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRACLE HOUSES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health