Healthcare Provider Details

I. General information

NPI: 1124980412
Provider Name (Legal Business Name): NATIVE MAGNOLIA HOLISTIC CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2781 HIGHWAY 145
SALTILLO MS
38866-9783
US

IV. Provider business mailing address

2781 HIGHWAY 145
SALTILLO MS
38866-9783
US

V. Phone/Fax

Practice location:
  • Phone: 662-372-5308
  • Fax:
Mailing address:
  • Phone: 662-372-5308
  • Fax: 833-973-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA KING
Title or Position: OWNER
Credential: NP
Phone: 662-372-5308