Provider Demographics
NPI:1043565542
Name:MAGNOLIA SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MAGNOLIA SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IVORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-234-5665
Mailing Address - Street 1:25 COLUMBIA ROAD 47
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753
Mailing Address - Country:US
Mailing Address - Phone:870-234-5665
Mailing Address - Fax:879-234-5665
Practice Address - Street 1:25 COLUMBIA ROAD 47
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-234-5665
Practice Address - Fax:870-234-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR295574OtherMEDICARE PTAN