=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174094304
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 626 VEROT SCHOOL RD STE C
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-5094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-210-2060
-----------------------------------------------------
Fax | 888-544-6008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5412 DIJON DR
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70808-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-615-8693
-----------------------------------------------------
Fax | 888-544-6008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MARISSA BEESLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-442-6493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------