| Entity Name: | MIRACLE COMMUNITY BEHAVIORAL CENTER CORP |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 25 Aug 2020 (4 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 16 Dec 2020 (4 years ago) |
| Document Number: | P20000067872 |
| FEI/EIN Number | 85-2824243 |
| Address: | 15660 SW 72 ST, MIAMI, FL, 33193, US |
| Mail Address: | 15660 SW 72 ST, MIAMI, FL, 33193, US |
| ZIP code: | 33193 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1700491552 | 2020-09-09 | 2023-08-25 | 15660 SW 72ND ST, MIAMI, FL, 331931923, US | 15660 SW 72ND ST, MIAMI, FL, 331931923, US | |||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 786-697-1150 |
Authorized person
| Name | BRISAIDA DUARTE |
| Role | CEO |
| Phone | 7866971150 |
Taxonomy
| Taxonomy Code | 208D00000X - General Practice Physician |
| Is Primary | Yes |
| Taxonomy Code | 225100000X - Physical Therapist |
| Is Primary | No |
| Taxonomy Code | 225200000X - Physical Therapy Assistant |
| Is Primary | No |
| Taxonomy Code | 251S00000X - Community/Behavioral Health Agency |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 118354400 |
| State | FL |
| Issuer | HEALTH CARE CLINIC CERTIFICATE (AHCA) |
| Number | 42711 |
| State | FL |
| Issuer | CAQH |
| Number | 15527884 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DUARTE BRISAIDA | Agent | 15660 SW 72 ST, MIAMI, FL, 33193 |
| Name | Role | Address |
|---|---|---|
| DUARTE BRISAIDA | President | 15660 SW 72 ST, MIAMI, FL, 33193 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G21000088754 | MIRACLE MEDICAL | ACTIVE | 2021-07-06 | 2026-12-31 | No data | 15660 SW 72 ST, MIAMI, FL, 33193 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2022-04-27 | 15660 SW 72 ST, MIAMI, FL 33193 | No data |
| AMENDMENT | 2020-12-16 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-28 |
| AMENDED ANNUAL REPORT | 2023-05-18 |
| ANNUAL REPORT | 2023-03-30 |
| AMENDED ANNUAL REPORT | 2022-04-27 |
| ANNUAL REPORT | 2022-01-05 |
| ANNUAL REPORT | 2021-01-19 |
| Amendment | 2020-12-16 |
| Domestic Profit | 2020-08-25 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
