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General NPI Number Information
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NPI Number | 1275902652
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MANOR LLC
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Dates
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Enumeration Date | 09/16/2015
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 751 N SOMERET CIR
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City | WASILLA
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State | AK
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Zip | 99654
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Country | US
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Telephone | 907-631-3354
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Fax | 907-631-3354
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Provider Business Mailing Address
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Address Line | PO BOX 874464
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City | WASILLA
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State | AK
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Zip | 99687-4464
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Country | US
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Telephone | 907-631-3354
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Fax | 907-631-3354
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CHERYL L SAYEN
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Credential | RN
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Telephone | 907-631-3354
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 101107
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License Number State | AK
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