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General NPI Number Information
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NPI Number | 1750536819
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Entity Type | Organization
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Legal Business Name | MAGNOLIA BLOOMS PCH,LLC
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Dates
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Enumeration Date | 11/17/2008
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Last Update Date | 11/17/2008
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Provider Practice Location Address
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Address Line | 1250 NICHOLSVILLE RD NW
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City | MONROE
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State | GA
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Zip | 30656-3469
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Country | US
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Telephone | 678-458-2011
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Fax |
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Provider Business Mailing Address
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Address Line | 1250 NICHOLSVILLE RD NW
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City | MONROE
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State | GA
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Zip | 30656-3469
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Country | US
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Telephone | 678-458-2011
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. SANDY WAGES BALLARD
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Credential |
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Telephone | 678-458-2011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 147-01-013-1
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License Number State | GA
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