MEDICARE: MAGNOLIA NURSING CENTER 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	314000000X	Skilled Nursing Facility	404	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366426082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA NURSING CENTER LLC

Provider Business Mailing Address
First Line	:	3701 PETER QUINN DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-3309
Country	:	US
Telephone Number	:	601-366-1712
Fax Number	:	601-366-1715

Provider Business Practice Location Address
First Line	:	3701 PETER QUINN DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-3309
Country	:	US
Telephone Number	:	601-366-1712
Fax Number	:	601-366-1715

Authorized Official
Title or Position	:	COMPTROLLER
Name	:	MRS. TINA L ELLIS
Credential	:
Telephone Number	:	601-304-0980

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	08/22/2020

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