Provider Demographics
NPI:1427543586
Name:MAGNOLIA MEDICAL COMPANY
Entity Type:Organization
Organization Name:MAGNOLIA MEDICAL COMPANY
Other - Org Name:MAGNOLIA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRADEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:RAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-209-5115
Mailing Address - Street 1:10515 E 40TH AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239-3264
Mailing Address - Country:US
Mailing Address - Phone:303-209-5115
Mailing Address - Fax:720-638-5562
Practice Address - Street 1:10515 40TH AVENUE SUITE 115
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239
Practice Address - Country:US
Practice Address - Phone:303-209-5115
Practice Address - Fax:720-504-3583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA MEDICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-29
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory