Healthcare Provider Details

I. General information

NPI: 1932965902
Provider Name (Legal Business Name): MAGNOLIA KIDS PEDIATRIC EXTENDED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 03/12/2024
Certification Date: 03/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 NAVAJO CIR
CLINTON MS
39056-3111
US

IV. Provider business mailing address

166 NAVAJO CIR
CLINTON MS
39056-3111
US

V. Phone/Fax

Practice location:
  • Phone: 601-503-3731
  • Fax:
Mailing address:
  • Phone: 601-503-3731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM3000X
TaxonomyMedically Fragile Infants and Children Day Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA D TURMAN
Title or Position: CO-OWNER AND DIRECTOR OF NURSING
Credential: RN, BSN
Phone: 601-503-3731