Provider Demographics
NPI:1538292743
Name:THE BLUE MAGNOLIA, LLC
Entity Type:Organization
Organization Name:THE BLUE MAGNOLIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-899-0232
Mailing Address - Street 1:PO BOX 2102
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28793-2102
Mailing Address - Country:US
Mailing Address - Phone:828-899-0232
Mailing Address - Fax:
Practice Address - Street 1:829 N JUSTICE ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3440
Practice Address - Country:US
Practice Address - Phone:828-899-0232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3409557251B00000X, 253Z00000X, 385H00000X
NC3408539251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408539Medicaid