Provider Demographics
NPI:1619394434
Name:POWER HOUSE MIRACLE CENTER
Entity Type:Organization
Organization Name:POWER HOUSE MIRACLE CENTER
Other - Org Name:THE KINGS HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-894-6828
Mailing Address - Street 1:10965 RIVER FALLS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-5138
Mailing Address - Country:US
Mailing Address - Phone:904-894-6828
Mailing Address - Fax:
Practice Address - Street 1:10965 RIVER FALLS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-5138
Practice Address - Country:US
Practice Address - Phone:904-894-6828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11620310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility