Healthcare Provider Details

I. General information

NPI: 1700418373
Provider Name (Legal Business Name): MAGNOLIA 1 HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E 38TH ST
HOUSTON TX
77022
US

IV. Provider business mailing address

505 E 38TH ST
HOUSTON TX
77022
US

V. Phone/Fax

Practice location:
  • Phone: 832-801-0294
  • Fax:
Mailing address:
  • Phone: 832-801-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: FRER BASS
Title or Position: PRESIDENT
Credential:
Phone: 832-801-0294