Provider Demographics
NPI:1093736753
Name:MAGNOLIA REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MAGNOLIA REGIONAL MEDICAL CENTER
Other - Org Name:MAGNOLIA HOME HEALTH AGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-235-3212
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754-0629
Mailing Address - Country:US
Mailing Address - Phone:870-235-3598
Mailing Address - Fax:870-235-3677
Practice Address - Street 1:833 N WASHINGTON
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-235-3598
Practice Address - Fax:870-235-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4240251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101604514Medicaid
AR17081OtherABCBS
AR17081OtherABCBS