Healthcare Provider Details

I. General information

NPI: 1306937974
Provider Name (Legal Business Name): MAGNOLIA HOSPITALITY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 BROADWAY BLUFFS DRIVE STE. 301
COLUMBIA MO
65201-8128
US

IV. Provider business mailing address

2475 BROADWAY BLUFFS DRIVE STE. 301
COLUMBIA MO
65201-8128
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-3235
  • Fax: 573-817-5917
Mailing address:
  • Phone: 573-874-3235
  • Fax: 573-817-5917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RACHNA PURI
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-874-3235