Provider Demographics
NPI:1306020615
Name:MIRACLE OUTLOOK FAMILY SERVICES
Entity Type:Organization
Organization Name:MIRACLE OUTLOOK FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-324-0048
Mailing Address - Street 1:2404 FERRAND ST
Mailing Address - Street 2:SUITE 21
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4954
Mailing Address - Country:US
Mailing Address - Phone:318-324-0048
Mailing Address - Fax:
Practice Address - Street 1:2404 FERRAND ST
Practice Address - Street 2:SUITE 21
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4954
Practice Address - Country:US
Practice Address - Phone:318-324-0048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10851251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1529559Medicaid