Provider Demographics
NPI:1639791411
Name:MIRACLE KIDS SUCCESS ACADEMY, INC.
Entity Type:Organization
Organization Name:MIRACLE KIDS SUCCESS ACADEMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-932-3600
Mailing Address - Street 1:1900 STILLWATER DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9119
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:
Practice Address - Street 1:1900 STILLWATER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9119
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR239436790Medicaid