Provider Demographics
NPI:1275101008
Name:MAGNOLIAS WAY LLC
Entity Type:Organization
Organization Name:MAGNOLIAS WAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:V
Authorized Official - Last Name:DACCHILLE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:786-308-1676
Mailing Address - Street 1:1020 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4547
Mailing Address - Country:US
Mailing Address - Phone:786-308-1676
Mailing Address - Fax:
Practice Address - Street 1:1020 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4547
Practice Address - Country:US
Practice Address - Phone:786-308-1676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNL000000028393OtherSTATE LICENSE