Provider Demographics
NPI:1386819308
Name:MAGIC CITY ENTERPRISES, INC
Entity Type:Organization
Organization Name:MAGIC CITY ENTERPRISES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:LILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-637-8869
Mailing Address - Street 1:1780 WESTLAND RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3322
Mailing Address - Country:US
Mailing Address - Phone:307-637-8869
Mailing Address - Fax:307-638-0467
Practice Address - Street 1:1780 WESTLAND RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3322
Practice Address - Country:US
Practice Address - Phone:307-637-8869
Practice Address - Fax:307-638-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 251C00000X
WY103TC0700X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100132911Medicaid
WY100132912Medicaid
WY100132901Medicaid