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General NPI Number Information
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NPI Number | 1356611966
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Entity Type | Organization
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Legal Business Name | MAGNOLIA NETWORK, LLC
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Dates
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Enumeration Date | 01/12/2012
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Last Update Date | 01/12/2012
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Provider Practice Location Address
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Address Line | 517 RADFORD BOULEVARD SUITE A
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City | DILLON
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State | SC
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Zip | 29536-2469
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Country | US
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Telephone | 843-627-0121
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Fax | 843-627-0122
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Provider Business Mailing Address
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Address Line | 517 RADFORD BOULEVARD SUITE A
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City | DILLON
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State | SC
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Zip | 29536-2469
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Country | US
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Telephone | 843-627-0121
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Fax | 843-627-0122
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MR. MICHAEL MONTES
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Credential |
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Telephone | 843-627-0121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 3232
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License Number State | SC
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