Healthcare Provider Details

I. General information

NPI: 1326244120
Provider Name (Legal Business Name): MAGNOLIA MANOR INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S LEE ST
AMERICUS GA
31709-4715
US

IV. Provider business mailing address

2001 S LEE ST
AMERICUS GA
31709-4715
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-9352
  • Fax:
Mailing address:
  • Phone: 229-924-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JERRY VICK
Title or Position: VP FINANCE
Credential:
Phone: 229-924-9352