Provider Demographics
NPI:1215368535
Name:MIRACLE ALF, INC.
Entity Type:Organization
Organization Name:MIRACLE ALF, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MILAGRO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-966-5335
Mailing Address - Street 1:8716 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2802
Mailing Address - Country:US
Mailing Address - Phone:813-966-5335
Mailing Address - Fax:813-442-4704
Practice Address - Street 1:8716 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2802
Practice Address - Country:US
Practice Address - Phone:813-966-5335
Practice Address - Fax:813-442-4704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11704310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility