Organization
MAGIC CITY ENTERPRISES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MANDY LILEY (BUSINESS MANAGER)
(307) 637-8869
Entity
Organization
Contact information
Practice address
1780 WESTLAND RD, CHEYENNE, WY 82001-3322
(307) 637-8869
(307) 638-0467
Mailing address
1780 WESTLAND RD, CHEYENNE, WY 82001-3322
(307) 637-8869
(307) 638-4467
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
1194895359
WY
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
1194895359
WY
320700000X
Physical Disabilities Residential Treatment Facility
1194895359
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1194895359
—
WY
01
—
W21288
MEDICARE PTAN
WY
Enumeration date
03/11/2015
Last updated
03/11/2015
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