Healthcare Provider Details

I. General information

NPI: 1972839777
Provider Name (Legal Business Name): MAGNOLIA HEALTH SYSTEMS XI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 LAFAYETTE PKWY
FLOYDS KNOBS IN
47119-9788
US

IV. Provider business mailing address

8455 KEYSTONE XING
INDIANAPOLIS IN
46240-4353
US

V. Phone/Fax

Practice location:
  • Phone: 812-923-4888
  • Fax:
Mailing address:
  • Phone: 317-818-1240
  • Fax: 317-818-0720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier09-012161-1
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name: STUART REED
Title or Position: MEMBER
Credential:
Phone: 317-818-1240