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NPI Code Detail

MEDICARE: MAGNOLIA DIAGNOSTICS, LLC

MEDICARE: MAGNOLIA DIAGNOSTICS, 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
1207ZP0105XClinical Pathology/Laboratory Medicine Physician
2291U00000XClinical Medical Laboratory

General Provider Information

NPI Number : 1922551399
Entity Type Code : Organization
Provider Name (Legal Business Name) : MAGNOLIA DIAGNOSTICS, LLC
Provider Business Mailing Address
First Line : 4245 N CENTRAL EXPY STE 420
Second Line :
City : DALLAS
State : TX
Zip : 75205-4566
Country : US
Telephone Number : 205-356-6790
Fax Number :
Provider Business Practice Location Address
First Line : 4245 N CENTRAL EXPY STE 420
Second Line :
City : DALLAS
State : TX
Zip : 75205-4566
Country : US
Telephone Number : 972-707-9929
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : JOHN BAINS
Credential :
Telephone Number : 205-356-6790
Provider Enumeration Date : 08/02/2016
Last Update Date : 09/18/2018

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Directions to “MAGNOLIA DIAGNOSTICS, LLC ” Practice Location

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