Healthcare Provider Details

I. General information

NPI: 1952196826
Provider Name (Legal Business Name): MAGNOLIA FUNCTIONAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 GARDNER RD STE 208
CHARLESTON SC
29407-1712
US

IV. Provider business mailing address

1064 GARDNER RD STE 208
CHARLESTON SC
29407-1712
US

V. Phone/Fax

Practice location:
  • Phone: 843-501-2333
  • Fax:
Mailing address:
  • Phone: 843-513-9577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA GREEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 843-513-9577