Provider Demographics
NPI:1255612412
Name:MAGICAL KIDS THERAPY
Entity type:Organization
Organization Name:MAGICAL KIDS THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-753-6355
Mailing Address - Street 1:3507 JAIME ZAPATA MEMORIAL HWY
Mailing Address - Street 2:STE 1 & 2
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-4769
Mailing Address - Country:US
Mailing Address - Phone:956-753-6355
Mailing Address - Fax:956-753-6331
Practice Address - Street 1:3507 JAIME ZAPATA MEMORIAL HWY
Practice Address - Street 2:STE 1 & 2
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-4769
Practice Address - Country:US
Practice Address - Phone:956-753-6355
Practice Address - Fax:956-753-6331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676709OtherMEDICARE PTAN
TX332120001Medicaid