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General NPI Number Information
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NPI Number | 1558545210
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MANOR OF TUPELO
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Dates
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Enumeration Date | 12/18/2007
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Last Update Date | 12/18/2007
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Provider Practice Location Address
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Address Line | 1514 COUNTY ROAD 41
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City | TUPELO
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State | MS
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Zip | 38801-0681
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Country | US
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Telephone | 662-842-6776
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Fax | 662-842-6512
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Provider Business Mailing Address
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Address Line | 1514 COUNTY ROAD 41
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City | TUPELO
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State | MS
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Zip | 38801-0681
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Country | US
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Telephone | 662-842-6776
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Fax | 662-842-6512
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. DONNA PHARR
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Credential |
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Telephone | 662-842-6776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 1000
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License Number State | MS
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