Organization
MINI MIRACLES PEDIATRIC THERAPY, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DOUGLAS EDWIN BROWN (CEO/OWNER)
(601) 624-1237
Entity
Organization
Contact information
Practice address
2214 E FAIRVIEW AVE, JOHNSON CITY, TN 37601-2860
(423) 928-6464
(423) 232-7970
Mailing address
PO BOX 191, JOHNSON CITY, TN 37605-0191
(423) 534-8897
(423) 328-8662
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
0119003962
VA
252Y00000X
Early Intervention Provider Agency
Primary
4611
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1477991560
—
VA
Enumeration date
06/11/2013
Last updated
10/03/2023
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