Provider Demographics
NPI:1427385277
Name:MIRACLE RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:MIRACLE RECOVERY CENTER, LLC
Other - Org Name:MIRACLE BY THE BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/CO-FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-450-4604
Mailing Address - Street 1:7668 EL CAMINO REAL
Mailing Address - Street 2:#104-704
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-7932
Mailing Address - Country:US
Mailing Address - Phone:866-538-8153
Mailing Address - Fax:760-814-8161
Practice Address - Street 1:3342 VENADO ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-7849
Practice Address - Country:US
Practice Address - Phone:866-538-8153
Practice Address - Fax:760-814-8161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-14
Last Update Date:2009-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370124AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility