Provider Demographics
NPI:1477923431
Name:MIRACLE ONE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MIRACLE ONE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:J
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-808-7694
Mailing Address - Street 1:24800 NORTHWESTERN HWY
Mailing Address - Street 2:LEVEL 1
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2319
Mailing Address - Country:US
Mailing Address - Phone:248-808-7694
Mailing Address - Fax:
Practice Address - Street 1:24800 NORTHWESTERN HWY
Practice Address - Street 2:LEVEL 1
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2319
Practice Address - Country:US
Practice Address - Phone:248-808-7694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicare PIN