Provider Demographics
NPI:1235675307
Name:MIRACLE MILE THERAPY LLC
Entity Type:Organization
Organization Name:MIRACLE MILE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:YARCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CLT
Authorized Official - Phone:315-534-3409
Mailing Address - Street 1:2780 N FLORIDA AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:HERNANDO
Mailing Address - State:FL
Mailing Address - Zip Code:34442-4390
Mailing Address - Country:US
Mailing Address - Phone:877-773-7123
Mailing Address - Fax:877-773-7123
Practice Address - Street 1:2780 N FLORIDA AVE
Practice Address - Street 2:UNIT 1 HERNANDO PLAZA
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442-4390
Practice Address - Country:US
Practice Address - Phone:877-773-7123
Practice Address - Fax:877-773-7123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT18040225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty