Healthcare Provider Details

I. General information

NPI: 1518483239
Provider Name (Legal Business Name): MAGNOLIA GARDENS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 07/21/2022
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: 301-552-2001
Mailing address:
  • Phone: 301-552-2000
  • Fax: 301-552-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateMD

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASST SECRETARY
Credential:
Phone: 505-468-4742