Provider Demographics
NPI:1124223078
Name:MIRACLE HOME CARE SERVICES LLC
Entity Type:Organization
Organization Name:MIRACLE HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:RUTHINA
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-598-8356
Mailing Address - Street 1:5736 N TRYON ST STE 130
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-6898
Mailing Address - Country:US
Mailing Address - Phone:704-598-8356
Mailing Address - Fax:
Practice Address - Street 1:5736 N TRYON ST STE 130
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-6898
Practice Address - Country:US
Practice Address - Phone:704-598-8356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3431251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418189Medicaid