Healthcare Provider Details

I. General information

NPI: 1366426082
Provider Name (Legal Business Name): MAGNOLIA NURSING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 PETER QUINN DR
JACKSON MS
39213-3309
US

IV. Provider business mailing address

3701 PETER QUINN DR
JACKSON MS
39213-3309
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-1712
  • Fax: 601-366-1715
Mailing address:
  • Phone: 601-366-1712
  • Fax: 601-366-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number404
License Number StateMS

VIII. Authorized Official

Name: MRS. TINA L ELLIS
Title or Position: COMPTROLLER
Credential:
Phone: 601-304-0980