Healthcare Provider Details

I. General information

NPI: 1508794520
Provider Name (Legal Business Name): MAGNOLIA HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 WESTHAMPTON DR
CHARLOTTE NC
28208-6050
US

IV. Provider business mailing address

1225 LOUISE AVE
CHARLOTTE NC
28205-2852
US

V. Phone/Fax

Practice location:
  • Phone: 980-239-9535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: HINSENE SAMSON
Title or Position: OWNER
Credential:
Phone: 980-239-9535