MEDICARE: MAGNOLIA REHABILITATION SERVICES INC

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	261Q00000X	Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center	5CF64	LA

General Provider Information

NPI Number	:	1881691194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA REHABILITATION SERVICES INC

Provider Business Mailing Address
First Line	:	4005 LAKESHORE DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71109-1927
Country	:	US
Telephone Number	:	318-840-9074
Fax Number	:	318-860-3025

Provider Business Practice Location Address
First Line	:	4005 LAKESHORE DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71109-1927
Country	:	US
Telephone Number	:	337-324-8465
Fax Number	:	318-676-3083

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MR. DEWARRENT LEE BRANTLEY
Credential	:
Telephone Number	:	318-840-9074

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	06/04/2025

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