Healthcare Provider Details

I. General information

NPI: 1619753043
Provider Name (Legal Business Name): GENTLE MAGNOLIA HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2059 E PASS RD UNIT S15
GULFPORT MS
39507-3761
US

IV. Provider business mailing address

2059 E PASS RD UNIT S15
GULFPORT MS
39507-3761
US

V. Phone/Fax

Practice location:
  • Phone: 228-547-9022
  • Fax:
Mailing address:
  • Phone: 228-547-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALISHIA WILLIAMS
Title or Position: OWNER
Credential:
Phone: 228-547-9022