Provider Demographics
NPI:1326244120
Name:MAGNOLIA MANOR INCORPORATED
Entity Type:Organization
Organization Name:MAGNOLIA MANOR INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-924-9352
Mailing Address - Street 1:2001 S LEE ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-4715
Mailing Address - Country:US
Mailing Address - Phone:229-924-9352
Mailing Address - Fax:
Practice Address - Street 1:2001 S LEE ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-4715
Practice Address - Country:US
Practice Address - Phone:229-924-9352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA MANOR INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-27
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00040785CMedicaid
GA1125310001Medicare NSC