MEDICARE: MAGNOLIA GROVE HEALTHCARE

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	261QP2300X	Primary Care Clinic/Center	12792	MS

General Provider Information

NPI Number	:	1710179395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA GROVE HEALTHCARE

Provider Business Mailing Address
First Line	:	PO BOX 1040
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39502-1040
Country	:	US
Telephone Number	:	228-863-4000
Fax Number	:	228-863-4003

Provider Business Practice Location Address
First Line	:	4333 15TH ST STE A
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-2525
Country	:	US
Telephone Number	:	228-863-4000
Fax Number	:	228-863-4003

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TRACEY DECENA
Credential	:
Telephone Number	:	228-863-4000

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	08/16/2007

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