Provider Demographics
NPI:1881904175
Name:MIRACLE CARE LLC
Entity type:Organization
Organization Name:MIRACLE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:586-549-4642
Mailing Address - Street 1:2727 2ND AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2658
Mailing Address - Country:US
Mailing Address - Phone:313-974-6480
Mailing Address - Fax:
Practice Address - Street 1:2727 2ND AVE STE 315
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2675
Practice Address - Country:US
Practice Address - Phone:313-974-6480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-9257OtherMEDICARE PTAN