Provider Demographics
NPI:1174385934
Name:MIRACLE MILE MEDICAL CENTER
Entity type:Organization
Organization Name:MIRACLE MILE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKELINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-905-9682
Mailing Address - Street 1:15910 VENTURA BLVD STE 1719
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2838
Mailing Address - Country:US
Mailing Address - Phone:310-905-9682
Mailing Address - Fax:
Practice Address - Street 1:15910 VENTURA BLVD STE 1719
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2838
Practice Address - Country:US
Practice Address - Phone:310-905-9682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health