Provider Demographics
NPI:1104292093
Name:MIRACLE HILLS PRIMARY CARE CENTER PC
Entity type:Organization
Organization Name:MIRACLE HILLS PRIMARY CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAMAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-905-2075
Mailing Address - Street 1:11819 MIRACLE HILLS DR STE 105
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-4428
Mailing Address - Country:US
Mailing Address - Phone:402-905-2075
Mailing Address - Fax:402-905-9864
Practice Address - Street 1:11819 MIRACLE HILLS DR STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4428
Practice Address - Country:US
Practice Address - Phone:402-905-2075
Practice Address - Fax:402-905-9864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty