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General NPI Number Information
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NPI Number | 1912138454
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Entity Type | Organization
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Legal Business Name | MAGNOLIA GARDENS PCH, INC
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Dates
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Enumeration Date | 07/31/2009
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Last Update Date | 03/12/2010
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Provider Practice Location Address
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Address Line | 5348 KELLEYS CREEK DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30088-3827
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Country | US
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Telephone | 770-469-8925
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Fax | 770-469-8925
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Provider Business Mailing Address
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Address Line | PO BOX 684
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City | LOVEJOY
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State | GA
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Zip | 30250-0684
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Country | US
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Telephone | 770-469-8925
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Fax | 770-469-8925
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. TERI D. CARGILL
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Credential |
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Telephone | 678-697-0575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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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 | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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