Healthcare Provider Details

I. General information

NPI: 1902139033
Provider Name (Legal Business Name): MAGNOLIA CLUBHOUSE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 MAGNOLIA DR
CLEVELAND OH
44106-1813
US

IV. Provider business mailing address

11101 MAGNOLIA DR
CLEVELAND OH
44106-1813
US

V. Phone/Fax

Practice location:
  • Phone: 216-721-3030
  • Fax: 216-721-0105
Mailing address:
  • Phone: 216-721-3030
  • Fax: 216-721-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LORI D'ANGELO
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 216-721-3030