Healthcare Provider Details

I. General information

NPI: 1114723871
Provider Name (Legal Business Name): MRS. WENDY LEE BAIRD MAGDALENO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 OLD PRESTON HWY S
SHEPHERDSVILLE KY
40165-6411
US

IV. Provider business mailing address

290 OLD PRESTON HWY S
SHEPHERDSVILLE KY
40165-6411
US

V. Phone/Fax

Practice location:
  • Phone: 714-737-3166
  • Fax:
Mailing address:
  • Phone: 714-737-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: