Provider Demographics
NPI:1558000851
Name:MAGNOLIA GRACE SENIOR CARE LLC
Entity Type:Organization
Organization Name:MAGNOLIA GRACE SENIOR CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:DINITRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:WRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-550-6021
Mailing Address - Street 1:910 S 8TH ST STE 130
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-6700
Mailing Address - Country:US
Mailing Address - Phone:478-550-6021
Mailing Address - Fax:
Practice Address - Street 1:910 S 8TH ST STE 130
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-6700
Practice Address - Country:US
Practice Address - Phone:478-550-6021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health