Provider Demographics
NPI:1174759765
Name:MIRACLE LIFE TRANSPORTATION
Entity type:Organization
Organization Name:MIRACLE LIFE TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEON
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-690-1427
Mailing Address - Street 1:4115 TEAL VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4115 TEAL VALLEY CT
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8650
Practice Address - Country:US
Practice Address - Phone:281-690-1427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)