=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265398945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLYA LANTYRN & LAUREL PORCHLYGHT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2025
-----------------------------------------------------
Last Update Date | 12/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14700 TIREMAN ST APT 2
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48228-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-439-0442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14700 TIREMAN ST APT 2
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48228-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-439-0442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER L EVON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-439-0442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------