Provider Demographics
NPI:1326261314
Name:MAGNOLIA MEDICAL RESOURCES INC
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL RESOURCES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GUTEKUNST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-439-4729
Mailing Address - Street 1:412 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-6007
Mailing Address - Country:US
Mailing Address - Phone:337-439-4729
Mailing Address - Fax:
Practice Address - Street 1:412 7TH ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-6007
Practice Address - Country:US
Practice Address - Phone:337-439-4729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPCA 4292251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1974757Medicaid