Provider Demographics
NPI:1134267081
Name:MIRACLE CITY HOSPICE, LLC
Entity type:Organization
Organization Name:MIRACLE CITY HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & COO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:BICKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-535-8200
Mailing Address - Street 1:6303 COWBOYS WAY STE 600
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-0329
Mailing Address - Country:US
Mailing Address - Phone:469-535-8200
Mailing Address - Fax:205-379-6720
Practice Address - Street 1:9150 S HILLS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BROADVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44147-3511
Practice Address - Country:US
Practice Address - Phone:440-397-4111
Practice Address - Fax:440-394-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0113HSP251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2030680Medicaid
OH2030680Medicaid