Provider Demographics
NPI:1558048926
Name:MIRACLE LIVING HOMECARE LLC
Entity Type:Organization
Organization Name:MIRACLE LIVING HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:763-221-6529
Mailing Address - Street 1:9401 WHITE OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-2677
Mailing Address - Country:US
Mailing Address - Phone:763-221-6529
Mailing Address - Fax:
Practice Address - Street 1:7038 BROOKLYN BLVD STE I
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1370
Practice Address - Country:US
Practice Address - Phone:763-221-6529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health