Healthcare Provider Details

I. General information

NPI: 1336687920
Provider Name (Legal Business Name): MAGNOLIA HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W LAGRANGE RD
HANOVER IN
47243-9439
US

IV. Provider business mailing address

9480 PRIORITY WAY WEST DR
INDIANAPOLIS IN
46240-1470
US

V. Phone/Fax

Practice location:
  • Phone: 812-866-2625
  • Fax:
Mailing address:
  • Phone: 317-818-1240
  • Fax: 317-818-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number16-0001151-1
License Number StateIN

VIII. Authorized Official

Name: WILLIAM R MUELLER
Title or Position: A/R MANAGER
Credential:
Phone: 317-818-1240