Healthcare Provider Details

I. General information

NPI: 1841027646
Provider Name (Legal Business Name): MAGNOLIA PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ALCORN DR STE 1B
CORINTH MS
38834-9071
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 662-293-7390
  • Fax: 662-293-7399
Mailing address:
  • Phone: 662-293-1288
  • Fax: 662-293-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDON REECE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 662-293-7678