Provider Demographics
NPI:1093382681
Name:MAGNOLIA GREEN FOOT AND ANKLE CENTER LLC
Entity Type:Organization
Organization Name:MAGNOLIA GREEN FOOT AND ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNGMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-500-0949
Mailing Address - Street 1:6055 HARBOUR PARK DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2160
Mailing Address - Country:US
Mailing Address - Phone:804-500-0949
Mailing Address - Fax:804-500-0946
Practice Address - Street 1:6055 HARBOUR PARK DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2160
Practice Address - Country:US
Practice Address - Phone:804-500-0949
Practice Address - Fax:804-500-0946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty