Organization
MIRACLES NETWORK AGENCY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANDREA LO (EXECUTIVE DIRECTOR)
(731) 285-6499
Entity
Organization
Contact information
Practice address
615 SUGG PL, DYERSBURG, TN 38024-3052
(731) 285-6499
Mailing address
615 SUGG PL, DYERSBURG, TN 38024-3052
(731) 285-6499
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
0298258
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
H60
—
TN
Enumeration date
11/08/2011
Last updated
12/26/2012
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