Healthcare Provider Details

I. General information

NPI: 1619482866
Provider Name (Legal Business Name): MAGNOLIA WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 E 6TH AVE
TALLAHASSEE FL
32303
US

IV. Provider business mailing address

1318 E 6TH AVE
TALLAHASSEE FL
32303-6506
US

V. Phone/Fax

Practice location:
  • Phone: 850-656-6606
  • Fax: 850-878-5246
Mailing address:
  • Phone: 850-656-6606
  • Fax: 850-878-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. ZACHARY RAYMON VERRIER
Title or Position: OWNER
Credential: DC
Phone: 850-656-6606