Basic Information
| Provider Information | |||||||||
| NPI: | 1164026589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRACLE KIDS SUCCESS ACADEMY OF PARAGOULD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3127 SOUTHWEST DR STE A | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724048404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703368100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1910 RECTOR RD | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724502004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702408900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8703368100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QD1600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
No ID Information.