Basic Information
| Provider Information | |||||||||
| NPI: | 1891147088 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIRACLE TOUCH PT PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2543 E 11TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112355011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178820550 | ||||||||
| FaxNumber: | 7186159409 | ||||||||
| Practice Location | |||||||||
| Address1: | 2543 E 11TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112355011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178820550 | ||||||||
| FaxNumber: | 7186159409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | BULANOV | ||||||||
| AuthorizedOfficialFirstName: | TATIANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9178820550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 020707 | NY | Y | Agencies | Early Intervention Provider Agency |
No ID Information.