Provider Demographics
NPI:1902319106
Name:A'MIRACLE CONSUMER DIRECTED SERVICE
Entity type:Organization
Organization Name:A'MIRACLE CONSUMER DIRECTED SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/VENDOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VENOLIA
Authorized Official - Middle Name:ANTIONETTE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-649-7736
Mailing Address - Street 1:3161 FEE FEE RD STE A
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3206
Mailing Address - Country:US
Mailing Address - Phone:314-649-7736
Mailing Address - Fax:314-738-9941
Practice Address - Street 1:3159 FEE FEE RD STE 215
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-3299
Practice Address - Country:US
Practice Address - Phone:314-649-7736
Practice Address - Fax:314-528-5294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========Medicaid