Healthcare Provider Details

I. General information

NPI: 1225534530
Provider Name (Legal Business Name): MAGNOLIA ALLERGY AND SKIN CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E LEAKE ST
CLINTON MS
39056-4204
US

IV. Provider business mailing address

124 HEIGHTS DR
CLINTON MS
39056-6602
US

V. Phone/Fax

Practice location:
  • Phone: 601-519-9562
  • Fax:
Mailing address:
  • Phone: 601-519-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number22223
License Number StateMS

VIII. Authorized Official

Name: DR. LAN ZHOU
Title or Position: PHYSICIAN
Credential: MD PHD
Phone: 601-519-9562