=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114723871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. WENDY LEE BAIRD MAGDALENO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2025
-----------------------------------------------------
Last Update Date | 02/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 OLD PRESTON HWY S
-----------------------------------------------------
City | SHEPHERDSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40165-6411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-737-3166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 OLD PRESTON HWY S
-----------------------------------------------------
City | SHEPHERDSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40165-6411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-737-3166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------