Provider Demographics
NPI:1033114319
Name:MAGNOLIA PLACE HEALTH CARE L L P
Entity Type:Organization
Organization Name:MAGNOLIA PLACE HEALTH CARE L L P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:MAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-444-2516
Mailing Address - Street 1:7150 GANTT ACCESS
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-5638
Mailing Address - Country:US
Mailing Address - Phone:817-444-2516
Mailing Address - Fax:
Practice Address - Street 1:1620 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3546
Practice Address - Country:US
Practice Address - Phone:936-336-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112906314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001772Medicaid
TX676011Medicare Oscar/Certification
TX172134202Medicare Oscar/Certification