Provider Demographics
NPI:1356670970
Name:MIRACLE EAR
Entity Type:Organization
Organization Name:MIRACLE EAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PCC
Authorized Official - Prefix:MISS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-474-5459
Mailing Address - Street 1:7171 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6254
Mailing Address - Country:US
Mailing Address - Phone:850-474-5459
Mailing Address - Fax:
Practice Address - Street 1:1871 WELLS RD
Practice Address - Street 2:UNIT 1
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2371
Practice Address - Country:US
Practice Address - Phone:904-269-5700
Practice Address - Fax:904-269-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech