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General NPI Number Information
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NPI Number | 1801340856
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 08/08/2016
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Last Update Date | 09/19/2024
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Provider Practice Location Address
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Address Line | 946 HARMONY RD
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City | EATONTON
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State | GA
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Zip | 31024-5877
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Country | US
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Telephone | 706-991-5320
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Fax | 866-720-5313
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Provider Business Mailing Address
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Address Line | 946 HARMONY RD STE B
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City | EATONTON
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State | GA
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Zip | 31024-5877
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Country | US
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Telephone | 706-991-5320
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Fax | 866-720-5313
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. JUSTIN LANCE
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Credential |
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Telephone | 478-453-2341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME53031
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License Number State | GA
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