Provider Demographics
NPI:1902634470
Name:MIRACULUM CENTER
Entity type:Organization
Organization Name:MIRACULUM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDULATIF
Authorized Official - Middle Name:HAMZA
Authorized Official - Last Name:ABDULRAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-366-9972
Mailing Address - Street 1:20430 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5098
Mailing Address - Country:US
Mailing Address - Phone:651-366-9972
Mailing Address - Fax:
Practice Address - Street 1:220 ROBERT ST S STE 204-6
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1677
Practice Address - Country:US
Practice Address - Phone:651-366-9972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-25
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency