Healthcare Provider Details

I. General information

NPI: 1336331685
Provider Name (Legal Business Name): MAGNOLIA GARDENS ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 WEST DR
LAUREL MS
39440-4703
US

IV. Provider business mailing address

945 WEST DR
LAUREL MS
39440-4703
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-6660
  • Fax: 601-428-4685
Mailing address:
  • Phone: 601-649-6660
  • Fax: 601-428-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number898
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number898
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number898
License Number StateMS

VIII. Authorized Official

Name: MRS. DEBORAH DARLENE STEVERSON
Title or Position: OWNER/ADMINISTRATOR
Credential: LPN
Phone: 601-649-6660