Healthcare Provider Details

I. General information

NPI: 1285060681
Provider Name (Legal Business Name): MAGNOLIA MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CARTER ST
VIDALIA LA
71373-3307
US

IV. Provider business mailing address

304 HIGHLAND BLVD SUITE B
NATCHEZ MS
39120-4624
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-6088
  • Fax: 318-336-6095
Mailing address:
  • Phone: 601-442-6493
  • Fax: 601-442-0999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID HYDE
Title or Position: MANAGING PARTNER
Credential:
Phone: 225-763-1314