Provider Demographics
NPI:1538287222
Name:MAGNOLIA WOODS SENIOR VILLAGE, INC
Entity Type:Organization
Organization Name:MAGNOLIA WOODS SENIOR VILLAGE, INC
Other - Org Name:THE GARDENS OF PAMLICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BARHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-745-8208
Mailing Address - Street 1:P.O. BOX 276
Mailing Address - Street 2:
Mailing Address - City:GRANTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28529-0276
Mailing Address - Country:US
Mailing Address - Phone:252-745-8208
Mailing Address - Fax:252-745-5424
Practice Address - Street 1:22 MAGNOLIA WAY
Practice Address - Street 2:
Practice Address - City:GRANTSBORO
Practice Address - State:NC
Practice Address - Zip Code:28529-0276
Practice Address - Country:US
Practice Address - Phone:252-745-8208
Practice Address - Fax:252-745-5424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA WOODS SENIOR VILLAGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 069001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7806722Medicaid