Provider Demographics
NPI:1457588238
Name:MIRACLE HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:MIRACLE HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERS
Authorized Official - Prefix:MRS
Authorized Official - First Name:YUSHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDGETTE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:910-538-1096
Mailing Address - Street 1:800 SHIPYARD BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6442
Mailing Address - Country:US
Mailing Address - Phone:910-538-1096
Mailing Address - Fax:
Practice Address - Street 1:800 SHIPYARD BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6442
Practice Address - Country:US
Practice Address - Phone:910-538-1096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7675194251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health