Provider Demographics
NPI:1275319527
Name:A MIRACLE PLACE INC
Entity Type:Organization
Organization Name:A MIRACLE PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:IMELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LENZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-408-5620
Mailing Address - Street 1:12674 HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12674 HOOVER ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4173
Practice Address - Country:US
Practice Address - Phone:310-408-5620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health