Provider Demographics
NPI:1336329200
Name:PRATTVILLE S&S, DBA MAGNOLIA WOOD LODGE
Entity Type:Organization
Organization Name:PRATTVILLE S&S, DBA MAGNOLIA WOOD LODGE
Other - Org Name:MW THERAPEUTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCARBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:334-514-5268
Mailing Address - Street 1:PO BOX 1227
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0020
Mailing Address - Country:US
Mailing Address - Phone:334-514-5268
Mailing Address - Fax:334-514-5269
Practice Address - Street 1:202 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-2723
Practice Address - Country:US
Practice Address - Phone:334-514-5268
Practice Address - Fax:334-514-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services