MEDICARE: MAGNOLIA DIAGNOSTIC SERVICES INC.

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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1770375768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA DIAGNOSTIC SERVICES INC.

Provider Business Mailing Address
First Line	:	4005 LAKESHORE DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71109-1927
Country	:	US
Telephone Number	:	318-840-9074
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 LAKESHORE DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71109-1927
Country	:	US
Telephone Number	:	318-840-9074
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	MR. DEWARRENT LEE BRANTLEY
Credential	:
Telephone Number	:	318-840-9074

Provider Enumeration Date	:	05/19/2025
Last Update Date	:	05/22/2025

Similar Medicare Providers

1881691194 — MAGNOLIA REHABILITATION SERVICES INC
Practice Location Address:

4005 LAKESHORE DR
SHREVEPORT, LA
71109-1927

Practice Phone: 337-324-8465
Practice Fax: 318-676-3083

1609435064 — J AND L A1 TRANSPORTATION
Practice Location Address:

3921 EILEEN LN
SHREVEPORT, LA
71109-1921

Practice Phone: 903-926-0640
Practice Fax:

1649279910 — THE DELTA PATHOLOGY GROUP, L.L.C.
Practice Location Address:

2915 MISSOURI AVE
SHREVEPORT, LA
71109-4327

Practice Phone: 318-621-8820
Practice Fax: 318-621-9525

1700874245 — DR. JANIS J. GULICK MD
Practice Location Address:

2915 MISSOURI AVE
SHREVEPORT, LA
71109-4327

Practice Phone: 318-364-2000
Practice Fax:

1063400513 — DR. GEORGE K. HARRISON MD
Practice Location Address:

2915 MISSOURI AVE
SHREVEPORT, LA
71109-4327

Practice Phone: 318-364-2000
Practice Fax:

1023006590 — DR. FREDRIC THOMAS SISKRON MD
Practice Location Address:

2915 MISSOURI AVE
SHREVEPORT, LA
71109-4327

Practice Phone: 318-364-2000
Practice Fax:

Directions to “MAGNOLIA DIAGNOSTIC SERVICES INC. ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.