Provider Demographics
NPI:1255835997
Name:MIRACLE ON 29TH STREET
Entity Type:Organization
Organization Name:MIRACLE ON 29TH STREET
Other - Org Name:KOALA-D MEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-302-1101
Mailing Address - Street 1:18210 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-1103
Mailing Address - Country:US
Mailing Address - Phone:480-302-1101
Mailing Address - Fax:
Practice Address - Street 1:18210 N 29TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1103
Practice Address - Country:US
Practice Address - Phone:480-302-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10509H171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ822395612Medicaid