MEDICARE: MAGNOLIA GRACE SENIOR CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1558000851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA GRACE SENIOR CARE LLC

Provider Business Mailing Address
First Line	:	910 S 8TH ST STE 130
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-6700
Country	:	US
Telephone Number	:	904-656-1315
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 S 8TH ST STE 130
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-6700
Country	:	US
Telephone Number	:	904-656-1315
Fax Number	:

Authorized Official
Title or Position	:	SOLE MBR
Name	:	DINITRA N WRICE
Credential	:
Telephone Number	:	904-855-5114

Provider Enumeration Date	:	06/03/2022
Last Update Date	:	07/17/2024

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