Provider Demographics
NPI:1184188104
Name:MIRACLE HOUSE INC
Entity Type:Organization
Organization Name:MIRACLE HOUSE INC
Other - Org Name:MIRACLE HOUSES INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-535-4447
Mailing Address - Street 1:7508 E INDEPENDENCE BLVD
Mailing Address - Street 2:STE 119
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9473
Mailing Address - Country:US
Mailing Address - Phone:704-535-4447
Mailing Address - Fax:704-535-4476
Practice Address - Street 1:332 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:TROUTMAN
Practice Address - State:NC
Practice Address - Zip Code:28166-9644
Practice Address - Country:US
Practice Address - Phone:704-535-4447
Practice Address - Fax:704-535-4476
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRACLE HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-23
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC35184242Medicaid
NC35184241Medicaid
NC3518424Medicaid