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General NPI Number Information
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NPI Number | 1346933181
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Entity Type | Organization
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Legal Business Name | MAGNOLIA WELLNESS INC.
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Dates
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Enumeration Date | 05/29/2023
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Last Update Date | 06/27/2023
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Provider Practice Location Address
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Address Line | 4295 GESNER ST STE 3F
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City | SAN DIEGO
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State | CA
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Zip | 92117-6667
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Country | US
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Telephone | 858-956-0514
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Fax |
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Provider Business Mailing Address
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Address Line | 3365 29TH STREET 1/2
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City | SAN DIEGO
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State | CA
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Zip | 92104
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Country | US
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Telephone | 619-887-0987
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KAILI JI SHUMILAK
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Credential | DO
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Telephone | 858-956-0514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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