Healthcare Provider Details

I. General information

NPI: 1700214400
Provider Name (Legal Business Name): MAGNOLIA MANOR SENIOR DAY PROGRAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 BARKS DR
FORT WALTON BEACH FL
32547-6774
US

IV. Provider business mailing address

141 BARKS DR
FORT WALTON BEACH FL
32547-6774
US

V. Phone/Fax

Practice location:
  • Phone: 850-225-2985
  • Fax:
Mailing address:
  • Phone: 850-225-2985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARA A. O'NEAL
Title or Position: OWNER/ADMINISTRATOR
Credential: CNA
Phone: 850-362-6556