Provider Demographics
NPI:1477638856
Name:MAGNOLIA PLACE OF NEW BERN, LLC
Entity Type:Organization
Organization Name:MAGNOLIA PLACE OF NEW BERN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-633-3455
Mailing Address - Street 1:PO BOX 1487
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27285-1487
Mailing Address - Country:US
Mailing Address - Phone:336-595-1075
Mailing Address - Fax:
Practice Address - Street 1:3407 OAKS RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-2718
Practice Address - Country:US
Practice Address - Phone:252-633-1143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-025-019310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804337Medicaid