Provider Demographics
NPI:1558654665
Name:WONDERFUL MOVING MIRACLE LLC
Entity Type:Organization
Organization Name:WONDERFUL MOVING MIRACLE LLC
Other - Org Name:WMMLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-354-4844
Mailing Address - Street 1:6657 CARRIAGE LANE AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2580
Mailing Address - Country:US
Mailing Address - Phone:330-354-4844
Mailing Address - Fax:330-494-3247
Practice Address - Street 1:6657 CARRIAGE LANE AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-2580
Practice Address - Country:US
Practice Address - Phone:330-354-4844
Practice Address - Fax:330-494-3247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1523810002251C00000X, 253J00000X, 253Z00000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3101888Medicaid