Healthcare Provider Details

I. General information

NPI: 1982175469
Provider Name (Legal Business Name): MAGNOLIA WELLNESS GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 EASTWOOD RD STE 313
WILMINGTON NC
28403-5728
US

IV. Provider business mailing address

809 WILD TURKEY PL
WILMINGTON NC
28405-4265
US

V. Phone/Fax

Practice location:
  • Phone: 910-375-7500
  • Fax:
Mailing address:
  • Phone: 910-375-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY LITZINGER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 910-375-7500