Healthcare Provider Details

I. General information

NPI: 1538204094
Provider Name (Legal Business Name): MAGNOLIA MANOR AT TUPELO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5427A FAIN LN
BELDEN MS
38826-9214
US

IV. Provider business mailing address

5427A FAIN LN
BELDEN MS
38826-9214
US

V. Phone/Fax

Practice location:
  • Phone: 662-397-2733
  • Fax:
Mailing address:
  • Phone: 662-397-2733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number1000
License Number StateMS

VIII. Authorized Official

Name: MRS. DEBRA D HAYNES
Title or Position: DIRECTOR ADMINISTRATIVE SERVICES
Credential:
Phone: 662-842-6776