Provider Demographics
NPI:1194842260
Name:MIRACLE HOME HEALTH AGENCY INC
Entity Type:Organization
Organization Name:MIRACLE HOME HEALTH AGENCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:C
Authorized Official - Last Name:OSUNWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-653-0668
Mailing Address - Street 1:10945 SOUTH STREET
Mailing Address - Street 2:#202A
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703
Mailing Address - Country:US
Mailing Address - Phone:562-653-0668
Mailing Address - Fax:562-653-0687
Practice Address - Street 1:10945 SOUTH STREET
Practice Address - Street 2:#202A
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703
Practice Address - Country:US
Practice Address - Phone:562-653-0668
Practice Address - Fax:562-653-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA70303FMedicaid
CA058143Medicare ID - Type Unspecified