Provider Demographics
NPI:1750849006
Name:MIRACLE KIDS SUCCESS ACADEMY OF PARAGOULD
Entity Type:Organization
Organization Name:MIRACLE KIDS SUCCESS ACADEMY OF PARAGOULD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-761-6680
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:870-932-3611
Practice Address - Street 1:1910 RECTOR RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-2004
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:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation