Healthcare Provider Details

I. General information

NPI: 1306630801
Provider Name (Legal Business Name): MAGNOLIA COMFORT MEDICAL SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7193 JONESBORO RD STE 101-102
MORROW GA
30260-2961
US

IV. Provider business mailing address

7193 JONESBORO RD STE 101-102
MORROW GA
30260-2961
US

V. Phone/Fax

Practice location:
  • Phone: 470-726-1699
  • Fax:
Mailing address:
  • Phone: 470-726-1699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KEVIN LE
Title or Position: CLINIC DIRECTOR / OWNER
Credential:
Phone: 678-268-8891