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General NPI Number Information
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NPI Number | 1881691194
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Entity Type | Organization
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Legal Business Name | MAGNOLIA REHABILITATION SERVICES INC
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 06/04/2025
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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 | 337-324-8465
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Fax | 318-676-3083
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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 | 318-860-3025
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Authorized Official
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Title or Position | OWNER/CEO
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 5CF64
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License Number State | LA
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