Provider Demographics
NPI:1366816985
Name:MAGNOLIA HOME CARE LLC
Entity Type:Organization
Organization Name:MAGNOLIA HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:757-831-2968
Mailing Address - Street 1:921 LEE SHORE CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0734
Mailing Address - Country:US
Mailing Address - Phone:866-866-2465
Mailing Address - Fax:866-866-2465
Practice Address - Street 1:921 LEE SHORE COURT
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0734
Practice Address - Country:US
Practice Address - Phone:866-866-2465
Practice Address - Fax:866-866-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0001062253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0001062OtherHOME CARE LICENSE NUMBER