Provider Demographics
NPI:1841908019
Name:MIRACLECLINIC
Entity type:Organization
Organization Name:MIRACLECLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-929-6581
Mailing Address - Street 1:2006 RESTON CIR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6110
Mailing Address - Country:US
Mailing Address - Phone:156-192-9658
Mailing Address - Fax:
Practice Address - Street 1:2006 RESTON CIR
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-6110
Practice Address - Country:US
Practice Address - Phone:156-192-9658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1922610971OtherNPI