Provider Demographics
NPI:1376547349
Name:MAGNOLIA OF MADISON, INC.
Entity Type:Organization
Organization Name:MAGNOLIA OF MADISON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, DON
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LEN
Authorized Official - Last Name:MACHEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-574-6400
Mailing Address - Street 1:708 LASALLE ST.
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282
Mailing Address - Country:US
Mailing Address - Phone:318-574-6400
Mailing Address - Fax:318-574-6401
Practice Address - Street 1:708 LASALLE ST.
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282
Practice Address - Country:US
Practice Address - Phone:318-574-6400
Practice Address - Fax:318-574-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA860251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1406503Medicaid
LA1406503Medicaid