Provider Demographics
NPI:1184191918
Name:MAGNOLIA CARE AFC HOME LLC
Entity Type:Organization
Organization Name:MAGNOLIA CARE AFC HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DEXTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-878-8352
Mailing Address - Street 1:9200 W WALKER RD
Mailing Address - Street 2:
Mailing Address - City:MANTON
Mailing Address - State:MI
Mailing Address - Zip Code:49663-9315
Mailing Address - Country:US
Mailing Address - Phone:231-839-4585
Mailing Address - Fax:
Practice Address - Street 1:9200 W WALKER RD
Practice Address - Street 2:
Practice Address - City:MANTON
Practice Address - State:MI
Practice Address - Zip Code:49663-9315
Practice Address - Country:US
Practice Address - Phone:231-839-4585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency