Provider Demographics
NPI:1932641248
Name:MAGIC STAR BEHAVIORAL GROUP
Entity Type:Organization
Organization Name:MAGIC STAR BEHAVIORAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-881-1471
Mailing Address - Street 1:1661 PEREGRINE FALCONS WAY
Mailing Address - Street 2:106
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-8056
Mailing Address - Country:US
Mailing Address - Phone:407-881-1471
Mailing Address - Fax:
Practice Address - Street 1:1661 PEREGRINE FALCONS WAY
Practice Address - Street 2:106
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-8056
Practice Address - Country:US
Practice Address - Phone:407-881-1471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management