Provider Demographics
NPI:1700491552
Name:MIRACLE COMMUNITY BEHAVIORAL CENTER CORP
Entity Type:Organization
Organization Name:MIRACLE COMMUNITY BEHAVIORAL CENTER CORP
Other - Org Name:MIRACLE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRISAIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-697-1150
Mailing Address - Street 1:15660 SW 72ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1923
Mailing Address - Country:US
Mailing Address - Phone:786-697-1150
Mailing Address - Fax:
Practice Address - Street 1:15660 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1923
Practice Address - Country:US
Practice Address - Phone:786-697-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-09
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118354400Medicaid
FL42711OtherHEALTH CARE CLINIC CERTIFICATE (AHCA)
FL15527884OtherCAQH