Healthcare Provider Details

I. General information

NPI: 1871050054
Provider Name (Legal Business Name): MAGNOLIA HOSPICE OF MACON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 BASS RD STE G
MACON GA
31210-7579
US

IV. Provider business mailing address

6900 SW 80TH ST
MIAMI FL
33143-4931
US

V. Phone/Fax

Practice location:
  • Phone: 470-281-8686
  • Fax: 877-663-8423
Mailing address:
  • Phone: 305-591-1606
  • Fax: 305-591-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ISMAEL ROQUE-VELASCO
Title or Position: PRESIDENT/CEO
Credential:
Phone: 305-591-1606