Provider Demographics
NPI:1679091789
Name:MIRACLE FARM, INC.
Entity Type:Organization
Organization Name:MIRACLE FARM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-836-0901
Mailing Address - Street 1:10802 FM 2621
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-0164
Mailing Address - Country:US
Mailing Address - Phone:979-836-0901
Mailing Address - Fax:979-277-0939
Practice Address - Street 1:10802 FM 2621
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-0164
Practice Address - Country:US
Practice Address - Phone:979-836-0901
Practice Address - Fax:979-277-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68824251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable