Healthcare Provider Details

I. General information

NPI: 1649893025
Provider Name (Legal Business Name): MAGNOLIAS HOME HEALTH AGENCY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 FOPPIANO LOOP
ROUND ROCK TX
78665-5638
US

IV. Provider business mailing address

1517 FOPPIANO LOOP
ROUND ROCK TX
78665-5638
US

V. Phone/Fax

Practice location:
  • Phone: 912-272-2991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LATASHA MACK
Title or Position: PRESIDENT
Credential:
Phone: 912-272-2991