Provider Demographics
NPI:1477566024
Name:MAGNOLIA SPECIAL CARE CENTER INC
Entity Type:Organization
Organization Name:MAGNOLIA SPECIAL CARE CENTER INC
Other - Org Name:SHEA FAMILY CARE MAGNOLIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF LEGAL COUNSEL
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-441-8771
Mailing Address - Street 1:635 S MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-6012
Mailing Address - Country:US
Mailing Address - Phone:619-442-8826
Mailing Address - Fax:619-442-0288
Practice Address - Street 1:635 S MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-6012
Practice Address - Country:US
Practice Address - Phone:619-442-8826
Practice Address - Fax:619-442-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090000072314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05890JMedicaid
CA055890Medicare Oscar/Certification