Provider Demographics
NPI:1992082788
Name:MIRACLES NETWORK AGENCY
Entity type:Organization
Organization Name:MIRACLES NETWORK AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-285-6499
Mailing Address - Street 1:615 SUGG PL
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3052
Mailing Address - Country:US
Mailing Address - Phone:731-285-6499
Mailing Address - Fax:
Practice Address - Street 1:615 SUGG PL
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3052
Practice Address - Country:US
Practice Address - Phone:731-285-6499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0298258302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH60Medicaid