Provider Demographics
NPI:1407853716
Name:MAGNOLIA COMPREHENSIVE OUTPATIENT REHABILIATION FACILITY INC.
Entity Type:Organization
Organization Name:MAGNOLIA COMPREHENSIVE OUTPATIENT REHABILIATION FACILITY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWARRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-676-0705
Mailing Address - Street 1:2005 CRESWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2201
Mailing Address - Country:US
Mailing Address - Phone:318-676-0705
Mailing Address - Fax:318-676-0709
Practice Address - Street 1:2005 CRESWELL AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2201
Practice Address - Country:US
Practice Address - Phone:318-676-0705
Practice Address - Fax:318-676-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1159310Medicaid
LA=========OtherTRI-CARESOUTHWEST
LA=========0OtherBLUECROSSBLUESHEILD OF LA