Healthcare Provider Details

I. General information

NPI: 1922551399
Provider Name (Legal Business Name): MAGNOLIA DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 N CENTRAL EXPY STE 420
DALLAS TX
75205-4566
US

IV. Provider business mailing address

4245 N CENTRAL EXPY STE 420
DALLAS TX
75205-4566
US

V. Phone/Fax

Practice location:
  • Phone: 972-707-9929
  • Fax:
Mailing address:
  • Phone: 205-356-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: JOHN BAINS
Title or Position: PRESIDENT
Credential:
Phone: 205-356-6790