Provider Demographics
NPI:1750817003
Name:TAILOR MADE OUTREACH COMPANY LLC
Entity Type:Organization
Organization Name:TAILOR MADE OUTREACH COMPANY LLC
Other - Org Name:MIRACLE HEALTHCARE PROVIDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHANAIREA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-649-4374
Mailing Address - Street 1:4107 HIXSON PIKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-3130
Mailing Address - Country:US
Mailing Address - Phone:704-649-4374
Mailing Address - Fax:
Practice Address - Street 1:301 HIGGINS AVE STE 108
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-3006
Practice Address - Country:US
Practice Address - Phone:704-649-4374
Practice Address - Fax:865-999-4961
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAILOR MADE OUTREACH COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X, 253Z00000X
TN1000000020165261QM1300X
TN261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No253J00000XAgenciesFoster Care Agency
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031164Medicaid