Healthcare Provider Details

I. General information

NPI: 1104464395
Provider Name (Legal Business Name): MAGNOLIA SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 HIGHWAY 72 W
CORINTH MS
38834-8556
US

IV. Provider business mailing address

401 ALCORN DR STE 2C
CORINTH MS
38834-9073
US

V. Phone/Fax

Practice location:
  • Phone: 662-665-8041
  • Fax: 662-665-8049
Mailing address:
  • Phone: 662-293-7618
  • Fax: 662-293-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: MARC NAKAGAWA
Title or Position: CFO
Credential:
Phone: 662-293-7660