Provider Demographics
NPI:1508982455
Name:MAGNOLIA FAMILY SERVICES LLC
Entity Type:Organization
Organization Name:MAGNOLIA FAMILY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:OLIVIER
Authorized Official - Suffix:II
Authorized Official - Credentials:MBA
Authorized Official - Phone:985-449-4055
Mailing Address - Street 1:1418 TIGER DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4337
Mailing Address - Country:US
Mailing Address - Phone:985-449-4055
Mailing Address - Fax:985-449-4178
Practice Address - Street 1:1418 TIGER DR
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4337
Practice Address - Country:US
Practice Address - Phone:985-449-4055
Practice Address - Fax:985-449-4178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1176621251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600720425OtherMAGELLAN HEALTH SERVICES
LA1176621Medicaid