Healthcare Provider Details

I. General information

NPI: 1851198444
Provider Name (Legal Business Name): MAGNOLIA MEDICAL AESTHETICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

IV. Provider business mailing address

1478 43RD LN
PUEBLO CO
81006-9307
US

V. Phone/Fax

Practice location:
  • Phone: 719-250-9412
  • Fax:
Mailing address:
  • Phone: 719-250-9412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONDA ORNDOFF
Title or Position: OWNER/PROVIDER
Credential: DNP
Phone: 719-250-9412