=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174308365
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA MEDICAL CENTER CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2023
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 NW 176TH ST STE 309
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-5048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-488-4550
-----------------------------------------------------
Fax | 786-219-3881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 NW 176TH ST STE 309
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-5048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-488-4550
-----------------------------------------------------
Fax | 786-219-3881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIGUEL ANGEL RIESTRA ROSA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 656-247-0009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------