Provider Demographics
NPI:1508393117
Name:MAGNOLIA WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:MAGNOLIA WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-718-9525
Mailing Address - Street 1:5687 COMMERCE
Mailing Address - Street 2:7
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5687 COMMERCE
Practice Address - Street 2:7
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775
Practice Address - Country:US
Practice Address - Phone:225-718-9525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health