Provider Demographics
NPI:1003678491
Name:MICHIGAN MAGICAL
Entity Type:Organization
Organization Name:MICHIGAN MAGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-587-6940
Mailing Address - Street 1:PO BOX 7048
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121-7048
Mailing Address - Country:US
Mailing Address - Phone:313-587-6940
Mailing Address - Fax:
Practice Address - Street 1:5870 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-3060
Practice Address - Country:US
Practice Address - Phone:313-587-6940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health