Provider Demographics
NPI:1902157605
Name:MIRACLES IN A BAG
Entity Type:Organization
Organization Name:MIRACLES IN A BAG
Other - Org Name:NONE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JERRILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOYD-HADLEY
Authorized Official - Suffix:I
Authorized Official - Credentials:LLC
Authorized Official - Phone:615-944-9851
Mailing Address - Street 1:320 OLD HICKORY BLVD APT 3008
Mailing Address - Street 2:UNIT 3008
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37221-1413
Mailing Address - Country:US
Mailing Address - Phone:615-944-9851
Mailing Address - Fax:
Practice Address - Street 1:320 OLD HICKORY BLVD APT 3008
Practice Address - Street 2:UNIT 3008
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-1413
Practice Address - Country:US
Practice Address - Phone:615-944-9851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRACLE IN A BAG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000010607302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN301400000XMedicaid