Provider Demographics
NPI:1316217367
Name:MAGNOLIA GARDENS ASSISTED LIVING, INC
Entity Type:Organization
Organization Name:MAGNOLIA GARDENS ASSISTED LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:STEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-477-9041
Mailing Address - Street 1:945 WEST DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4703
Mailing Address - Country:US
Mailing Address - Phone:601-477-9041
Mailing Address - Fax:
Practice Address - Street 1:945 WEST DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4703
Practice Address - Country:US
Practice Address - Phone:601-477-9041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS898310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00585888Medicaid