Provider Demographics
NPI:1588647754
Name:MAGNOLIA MANOR, INC.
Entity Type:Organization
Organization Name:MAGNOLIA MANOR, INC.
Other - Org Name:MAGNOLIA MANOR NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HILL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-931-5942
Mailing Address - Street 1:2001 S LEE ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-4715
Mailing Address - Country:US
Mailing Address - Phone:229-924-9352
Mailing Address - Fax:229-931-5999
Practice Address - Street 1:2001 S LEE ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-4715
Practice Address - Country:US
Practice Address - Phone:229-924-9352
Practice Address - Fax:229-931-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1129065314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00040785AMedicaid
GA00040785AMedicaid