=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740466937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA LANE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2008
-----------------------------------------------------
Last Update Date | 01/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3510 CAMDEN RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-7717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-425-8751
-----------------------------------------------------
Fax | 910-644-1257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3510 CAMDEN RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-7717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-425-8751
-----------------------------------------------------
Fax | 910-644-1257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JUDY B TEW
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 910-425-8751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | SCL026031
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------