MEDICARE: MAGIG KINGDOM KIDS SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1447031562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGIG KINGDOM KIDS SERVICES LLC

Provider Business Mailing Address
First Line	:	6827 PARTRIDGE LN STE E
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32807-5312
Country	:	US
Telephone Number	:	954-592-6596
Fax Number	:

Provider Business Practice Location Address
First Line	:	6827 PARTRIDGE LN STE E
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32807-5312
Country	:	US
Telephone Number	:	954-592-6596
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. WUILMAY DEURITH VARELA MORAN
Credential	:
Telephone Number	:	954-592-6596

Provider Enumeration Date	:	10/13/2023
Last Update Date	:	10/13/2023

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