Provider Demographics
NPI:1053448522
Name:MAGNOLIS GARDENS, INC
Entity Type:Organization
Organization Name:MAGNOLIS GARDENS, INC
Other - Org Name:MAGNOLIA GARDENS SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-535-5006
Mailing Address - Street 1:PO BOX 2042
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-1242
Mailing Address - Country:US
Mailing Address - Phone:252-535-5006
Mailing Address - Fax:
Practice Address - Street 1:829 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2717
Practice Address - Country:US
Practice Address - Phone:252-308-1743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-042-002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802782Medicaid