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General NPI Number Information
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NPI Number | 1649021114
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Entity Type | Organization
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Legal Business Name | MAGNOLIA BRIDGE LLC
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Dates
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Enumeration Date | 04/01/2024
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Last Update Date | 04/01/2024
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Provider Practice Location Address
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Address Line | 1567 HUNTINGTON LN
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City | CLEARWATER
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State | FL
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Zip | 33755-1338
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Country | US
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Telephone | 727-225-4305
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Fax |
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Provider Business Mailing Address
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Address Line | 1345 SANDY LN
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City | CLEARWATER
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State | FL
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Zip | 33755-2042
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Country | US
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Telephone | 727-225-4305
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JASMINE MARIE FISHER
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Credential |
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Telephone | 727-225-4305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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