Healthcare Provider Details

I. General information

NPI: 1386819308
Provider Name (Legal Business Name): MAGIC CITY ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 WESTLAND RD
CHEYENNE WY
82001-3322
US

IV. Provider business mailing address

1780 WESTLAND RD
CHEYENNE WY
82001-3322
US

V. Phone/Fax

Practice location:
  • Phone: 307-637-8869
  • Fax: 307-638-0467
Mailing address:
  • Phone: 307-637-8869
  • Fax: 307-638-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateWY

VIII. Authorized Official

Name: MS. MANDY JANE LILEY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 307-637-8869