Provider Demographics
NPI:1568120970
Name:MAGNOLIA PODIATRY LLC
Entity Type:Organization
Organization Name:MAGNOLIA PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-507-3919
Mailing Address - Street 1:22 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1710
Mailing Address - Country:US
Mailing Address - Phone:203-507-3919
Mailing Address - Fax:
Practice Address - Street 1:22 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1710
Practice Address - Country:US
Practice Address - Phone:203-507-3919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty