Provider Demographics
NPI:1154675403
Name:MIRACLE HOUSES, INCORPORATED
Entity Type:Organization
Organization Name:MIRACLE HOUSES, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-369-1445
Mailing Address - Street 1:544 MULBERRY ST STE 613
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6324
Mailing Address - Country:US
Mailing Address - Phone:704-315-3895
Mailing Address - Fax:704-535-4476
Practice Address - Street 1:260 18TH ST NW
Practice Address - Street 2:UNIT 10212
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30363
Practice Address - Country:US
Practice Address - Phone:704-315-3895
Practice Address - Fax:704-535-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1861796179Medicaid