Provider Demographics
NPI:1780908228
Name:MIRACLE HEALTHCARE LLC
Entity type:Organization
Organization Name:MIRACLE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MESSENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-658-2885
Mailing Address - Street 1:649B W MCNEAL ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-2519
Mailing Address - Country:US
Mailing Address - Phone:731-658-2885
Mailing Address - Fax:731-658-2886
Practice Address - Street 1:649B W MCNEAL ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2519
Practice Address - Country:US
Practice Address - Phone:731-658-2885
Practice Address - Fax:731-658-2886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty