Provider Demographics
NPI:1851676506
Name:MIRACLE WORKERS C.L.A. LLC
Entity Type:Organization
Organization Name:MIRACLE WORKERS C.L.A. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-247-8424
Mailing Address - Street 1:PO BOX 7071
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31418-7071
Mailing Address - Country:US
Mailing Address - Phone:912-247-8424
Mailing Address - Fax:
Practice Address - Street 1:5 VINEYARD HAVEN DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-8250
Practice Address - Country:US
Practice Address - Phone:912-247-8424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH001449310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility