Provider Demographics
NPI:1568678217
Name:MIRACLE KIDS LLC
Entity Type:Organization
Organization Name:MIRACLE KIDS LLC
Other - Org Name:LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RABINDER
Authorized Official - Middle Name:KAUR
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:678-799-3599
Mailing Address - Street 1:1442 DRESDEN DR NE UNIT C258
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3590
Mailing Address - Country:US
Mailing Address - Phone:678-779-3599
Mailing Address - Fax:678-922-1235
Practice Address - Street 1:1442 DRESDEN DR NE UNIT C258
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3590
Practice Address - Country:US
Practice Address - Phone:678-779-3599
Practice Address - Fax:678-922-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002706225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000874849BMedicaid