Healthcare Provider Details

I. General information

NPI: 1437247780
Provider Name (Legal Business Name): MAGNOLIA HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MILLS ST
BROOKHAVEN MS
39601-2521
US

IV. Provider business mailing address

PO BOX 40018
BATON ROUGE LA
70835-0018
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-5608
  • Fax: 601-833-5285
Mailing address:
  • Phone: 225-753-0864
  • Fax: 225-753-0948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number349
License Number StateMS

VIII. Authorized Official

Name: RICHARD THOMAS DASPIT SR.
Title or Position: CEO
Credential:
Phone: 225-906-4644