MEDICARE: MAGNOLA MANOR AT DAYTONA BEACH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AL8869	FL

General Provider Information

NPI Number	:	1134675234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLA MANOR AT DAYTONA BEACH, LLC

Provider Business Mailing Address
First Line	:	59 LAKE MORTON DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-5344
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	252 FOREST LAKE BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32119-8106
Country	:	US
Telephone Number	:	863-226-0358
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	SAVITRI JOHNSON
Credential	:
Telephone Number	:	863-226-0358

Provider Enumeration Date	:	08/29/2016
Last Update Date	:	02/16/2022

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