Provider Demographics
NPI:1508143447
Name:MIRACLE VALLY ASSISTING LIVING
Entity Type:Organization
Organization Name:MIRACLE VALLY ASSISTING LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARTRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-865-3132
Mailing Address - Street 1:800 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4715
Practice Address - Country:US
Practice Address - Phone:469-865-3132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility