Healthcare Provider Details

I. General information

NPI: 1679366959
Provider Name (Legal Business Name): SOUTHERN MAGNOLIA ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 FLEURIE DR
KENNER LA
70065-1117
US

IV. Provider business mailing address

613 FLEURIE DR
KENNER LA
70065-1117
US

V. Phone/Fax

Practice location:
  • Phone: 504-644-6334
  • Fax:
Mailing address:
  • Phone: 504-644-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD HACKETT
Title or Position: OWNER
Credential:
Phone: 504-644-6334