Healthcare Provider Details

I. General information

NPI: 1912531427
Provider Name (Legal Business Name): MAGNOLIA PERSONAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 BO STAMPLEY RD
FAYETTE MS
39069-4879
US

IV. Provider business mailing address

PO BOX 2352
FAYETTE MS
39069-2352
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-1303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. FERLESHA KELLY
Title or Position: PRESIDENT
Credential:
Phone: 601-786-1303