Healthcare Provider Details

I. General information

NPI: 1508982455
Provider Name (Legal Business Name): MAGNOLIA FAMILY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 TIGER DR
THIBODAUX LA
70301-4337
US

IV. Provider business mailing address

1418 TIGER DR
THIBODAUX LA
70301-4337
US

V. Phone/Fax

Practice location:
  • Phone: 985-449-4055
  • Fax: 985-449-4178
Mailing address:
  • Phone: 985-449-4055
  • Fax: 985-449-4178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1176621
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD B OLIVIER II
Title or Position: CEO
Credential: MBA
Phone: 985-449-4055