Healthcare Provider Details

I. General information

NPI: 1114693579
Provider Name (Legal Business Name): SOUTHERN MAGNOLIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12856 BANYAN CREEK DR # 2
FORT MYERS FL
33908-3082
US

IV. Provider business mailing address

17165 JOHN MORRIS RD 291
FT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 239-265-5367
  • Fax:
Mailing address:
  • Phone: 239-265-5367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JAMIE GEERKEN
Title or Position: OWNER
Credential: COTA
Phone: 239-265-5367