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General NPI Number Information
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NPI Number | 1770375768
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Entity Type | Organization
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Legal Business Name | MAGNOLIA DIAGNOSTIC SERVICES INC.
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Dates
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Enumeration Date | 05/19/2025
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 4005 LAKESHORE DR
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City | SHREVEPORT
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State | LA
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Zip | 71109-1927
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Country | US
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Telephone | 318-840-9074
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Fax |
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Provider Business Mailing Address
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Address Line | 4005 LAKESHORE DR
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City | SHREVEPORT
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State | LA
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Zip | 71109-1927
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Country | US
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Telephone | 318-840-9074
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | MR. DEWARRENT LEE BRANTLEY
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Credential |
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Telephone | 318-840-9074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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