Provider Demographics
NPI:1053174391
Name:MIRACLE HOPE SUPPORTIVE HOME CARE LLC
Entity type:Organization
Organization Name:MIRACLE HOPE SUPPORTIVE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CENCREAHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-815-5158
Mailing Address - Street 1:5202 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2749
Mailing Address - Country:US
Mailing Address - Phone:414-275-7044
Mailing Address - Fax:
Practice Address - Street 1:4467 N 85TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-5141
Practice Address - Country:US
Practice Address - Phone:920-815-5158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care