Organization
MIRACLE ON 29TH STREET
Active
Other names
Koala-D Meds
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TROY BERKLEY (OWNER)
(480) 302-1101
Entity
Organization
Contact information
Practice address
18210 N 29TH ST, PHOENIX, AZ 85032-1103
(480) 302-1101
Mailing address
18210 N 29TH ST, PHOENIX, AZ 85032-1103
(480) 302-1101
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
AL10509H
AZ
Other
Enumeration date
03/19/2018
Last updated
09/12/2025
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