Provider Demographics
NPI:1578959409
Name:M'AGINE SUPPORTED LIVING
Entity Type:Organization
Organization Name:M'AGINE SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-851-0311
Mailing Address - Street 1:4626 WEBER RD STE 21
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-3542
Mailing Address - Country:US
Mailing Address - Phone:361-851-0311
Mailing Address - Fax:
Practice Address - Street 1:4626 WEBER RD STE 21
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-3542
Practice Address - Country:US
Practice Address - Phone:361-851-0311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization