Provider Demographics
NPI:1164510475
Name:MAGNOLIA HEALTHCARE, INC.
Entity Type:Organization
Organization Name:MAGNOLIA HEALTHCARE, INC.
Other - Org Name:AUTUMN LEAVES NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DASPIT
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:225-906-4644
Mailing Address - Street 1:PO BOX 40018
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70835-0018
Mailing Address - Country:US
Mailing Address - Phone:225-753-0864
Mailing Address - Fax:225-753-0948
Practice Address - Street 1:570 SOLOMON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-2771
Practice Address - Country:US
Practice Address - Phone:662-335-5863
Practice Address - Fax:662-335-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS494314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS220307Medicaid
MS220307Medicaid