Healthcare Provider Details

I. General information

NPI: 1346699071
Provider Name (Legal Business Name): MAGNOLIA GARDENS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 MALLERY DR
LANHAM MD
20706-3964
US

IV. Provider business mailing address

6710 MALLERY DR
LANHAM MD
20706-3964
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-2000
  • Fax:
Mailing address:
  • Phone: 301-552-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16011
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number16011
License Number StateMD

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752