Provider Demographics
NPI:1437796265
Name:MAGNOLIA SENIOR LIVING
Entity Type:Organization
Organization Name:MAGNOLIA SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:813-213-8967
Mailing Address - Street 1:3935 UPPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6876
Mailing Address - Country:US
Mailing Address - Phone:813-213-8967
Mailing Address - Fax:813-535-7990
Practice Address - Street 1:3935 UPPER CREEK DR
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6876
Practice Address - Country:US
Practice Address - Phone:813-213-8967
Practice Address - Fax:813-535-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility