Healthcare Provider Details

I. General information

NPI: 1649021114
Provider Name (Legal Business Name): MAGNOLIA BRIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1567 HUNTINGTON LN
CLEARWATER FL
33755-1338
US

IV. Provider business mailing address

1345 SANDY LN
CLEARWATER FL
33755-2042
US

V. Phone/Fax

Practice location:
  • Phone: 727-225-4305
  • Fax:
Mailing address:
  • Phone: 727-225-4305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JASMINE MARIE FISHER
Title or Position: MANAGER
Credential:
Phone: 727-225-4305