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General NPI Number Information
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NPI Number | 1740261411
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MANOR NURSING & REHAB CNTR LLC
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Dates
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Enumeration Date | 11/09/2005
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 1411 CLAIBORNE AVE
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City | SHREVEPORT
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State | LA
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Zip | 71103-4203
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Country | US
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Telephone | 318-868-4421
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Fax | 318-868-4431
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Provider Business Mailing Address
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Address Line | PO BOX 38270
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City | SHREVEPORT
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State | LA
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Zip | 71133-8270
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Country | US
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Telephone | 318-868-4421
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Fax | 318-868-4431
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. TEDDY RAY PRICE
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Credential |
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Telephone | 318-628-4116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 204
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License Number State | LA
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