Provider Demographics
NPI:1447783956
Name:MIRACLEO OF LOVE, INC.
Entity Type:Organization
Organization Name:MIRACLEO OF LOVE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGUS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:407-843-1760
Mailing Address - Street 1:741 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7343
Mailing Address - Country:US
Mailing Address - Phone:407-843-1760
Mailing Address - Fax:407-843-1767
Practice Address - Street 1:741 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7343
Practice Address - Country:US
Practice Address - Phone:407-843-1760
Practice Address - Fax:407-843-1767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL9220132Medicaid