Provider Demographics
NPI:1154755411
Name:MIRACLE BOARD AND CARE&ASSSISTED LIVING
Entity type:Organization
Organization Name:MIRACLE BOARD AND CARE&ASSSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SARAFYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-439-0611
Mailing Address - Street 1:17646 CALVERT ST
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1216
Mailing Address - Country:US
Mailing Address - Phone:818-344-1650
Mailing Address - Fax:818-344-1753
Practice Address - Street 1:17646 CALVERT ST
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1216
Practice Address - Country:US
Practice Address - Phone:818-344-1650
Practice Address - Fax:818-344-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197608216302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA197608216OtherLIC. RESIDENTIL CARE FACILITY