Provider Demographics
NPI:1619755501
Name:MAGDAN LLC
Entity Type:Organization
Organization Name:MAGDAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCHUGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-372-6141
Mailing Address - Street 1:9405 CYPRESS LAKE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-0909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9405 CYPRESS LAKE DR STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-0909
Practice Address - Country:US
Practice Address - Phone:239-372-6141
Practice Address - Fax:239-936-3391
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGDAN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-20
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty