Healthcare Provider Details

I. General information

NPI: 1881959401
Provider Name (Legal Business Name): MAGNOLIA SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 HWY. 72 WEST
CORINTH MS
38834-8556
US

IV. Provider business mailing address

P.O. BOX 2040
CORINTH MS
38835-2040
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HOWARD NELSON
Title or Position: VP PHYSICIAN SERVICES
Credential:
Phone: 662-293-7618