Provider Demographics
NPI:1851667703
Name:MIRACLE HOME HEALTH OF WISCONSIN INC
Entity Type:Organization
Organization Name:MIRACLE HOME HEALTH OF WISCONSIN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ARKADIY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPSHTEYN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:414-797-2254
Mailing Address - Street 1:7545 N PORT WASHINGTON RD STE 3
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3422
Mailing Address - Country:US
Mailing Address - Phone:414-915-0838
Mailing Address - Fax:414-797-4544
Practice Address - Street 1:7545 N PORT WASHINGTON RD STE 3
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3422
Practice Address - Country:US
Practice Address - Phone:414-797-2254
Practice Address - Fax:888-910-5128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1174251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100039227Medicaid
52-7319Medicare PIN