Healthcare Provider Details

I. General information

NPI: 1922307586
Provider Name (Legal Business Name): MAGNOLIA RETIREMENT HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 MAGNOLIA AVE
SEBRING FL
33870-3613
US

IV. Provider business mailing address

149 MAGNOLIA AVE
SEBRING FL
33870-3613
US

V. Phone/Fax

Practice location:
  • Phone: 863-382-2116
  • Fax: 863-382-2117
Mailing address:
  • Phone: 863-382-2116
  • Fax: 863-382-2117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL4947
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL4947
License Number StateFL

VIII. Authorized Official

Name: MR. MANUEL M DOMISIW
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 863-382-2116