MEDICARE: MAGNOLIA SENIOR CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	404	MS

General Provider Information

NPI Number	:	1427240779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA SENIOR CARE LLC

Provider Business Mailing Address
First Line	:	3701 PETER QUINN DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-3309
Country	:	US
Telephone Number	:	601-366-1712
Fax Number	:	601-366-1715

Provider Business Practice Location Address
First Line	:	3701 PETER QUINN DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-3309
Country	:	US
Telephone Number	:	601-366-1712
Fax Number	:	601-366-1715

Authorized Official
Title or Position	:	COMPTROLLER
Name	:	MRS. TINA ELLIS
Credential	:
Telephone Number	:	601-366-1712

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	08/10/2007

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Directions to “MAGNOLIA SENIOR CARE LLC ” Practice Location

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