Healthcare Provider Details

I. General information

NPI: 1174440523
Provider Name (Legal Business Name): MAGNOLIA RECREATION AND SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 MORGAN RD
LENA MS
39094-9254
US

IV. Provider business mailing address

1411 MORGAN RD
LENA MS
39094-9254
US

V. Phone/Fax

Practice location:
  • Phone: 601-300-2797
  • Fax:
Mailing address:
  • Phone: 601-300-2797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LAKESHIA EVON KENNEDY
Title or Position: MANAGER
Credential:
Phone: 601-300-2797