Provider Demographics
NPI:1598104507
Name:MAGNOLIA COURT ASSISTED LIVING
Entity Type:Organization
Organization Name:MAGNOLIA COURT ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:BRINN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-613-3029
Mailing Address - Street 1:103 YACHT HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2627
Mailing Address - Country:US
Mailing Address - Phone:321-613-3029
Mailing Address - Fax:321-613-3029
Practice Address - Street 1:103 YACHT HAVEN DR
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2627
Practice Address - Country:US
Practice Address - Phone:321-613-3029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11993310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility