Provider Demographics
NPI:1508303348
Name:MAGNOLIA FAMILY CLINIC
Entity Type:Organization
Organization Name:MAGNOLIA FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-1076
Mailing Address - Street 1:401 ALCORN DR STE 2C
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9073
Mailing Address - Country:US
Mailing Address - Phone:662-293-7618
Mailing Address - Fax:662-293-4358
Practice Address - Street 1:82 MAIN ST
Practice Address - Street 2:
Practice Address - City:RIENZI
Practice Address - State:MS
Practice Address - Zip Code:38865-9144
Practice Address - Country:US
Practice Address - Phone:662-293-6699
Practice Address - Fax:662-293-6698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-31
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty