Provider Demographics
NPI:1326241332
Name:MAGIC CIRCLE ADULT DAY HEALTH CARE CENTER INC.
Entity Type:Organization
Organization Name:MAGIC CIRCLE ADULT DAY HEALTH CARE CENTER INC.
Other - Org Name:DBA PRAIRIE PLACE ADULT DAY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-674-8345
Mailing Address - Street 1:105 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1969
Mailing Address - Country:US
Mailing Address - Phone:310-674-8345
Mailing Address - Fax:
Practice Address - Street 1:105 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1969
Practice Address - Country:US
Practice Address - Phone:310-674-8345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAADU70125FMedicaid