Healthcare Provider Details

I. General information

NPI: 1104598762
Provider Name (Legal Business Name): MAGNOLIA HEALTH AND WELLNESS CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 DRYDEN LOOP
DRYDEN VA
24243-8551
US

IV. Provider business mailing address

PO BOX 120
DRYDEN VA
24243-0120
US

V. Phone/Fax

Practice location:
  • Phone: 276-296-0966
  • Fax: 949-503-8066
Mailing address:
  • Phone: 276-296-0966
  • Fax: 949-503-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. RODNEY TERRY
Title or Position: ADMINISTRATOR
Credential:
Phone: 252-452-6075