Provider Demographics
NPI:1487184560
Name:MIRACLE RANCH
Entity Type:Organization
Organization Name:MIRACLE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GAEDT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:760-834-1586
Mailing Address - Street 1:73730 HIGHWAY 111 STE 8
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-4018
Mailing Address - Country:US
Mailing Address - Phone:760-834-1586
Mailing Address - Fax:
Practice Address - Street 1:73730 HIGHWAY 111 STE 8
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4018
Practice Address - Country:US
Practice Address - Phone:760-834-1586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health