Provider Demographics
NPI:1679668784
Name:MAGNOLIA HEALTHCARE REHABILITATION SERVICES
Entity Type:Organization
Organization Name:MAGNOLIA HEALTHCARE REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-296-2552
Mailing Address - Street 1:PO BOX 16325
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-6325
Mailing Address - Country:US
Mailing Address - Phone:601-296-2552
Mailing Address - Fax:601-296-2554
Practice Address - Street 1:1 LINCOLN PKWY
Practice Address - Street 2:SUITE104
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3262
Practice Address - Country:US
Practice Address - Phone:601-268-3292
Practice Address - Fax:601-296-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01537007Medicaid
MSDA5495OtherRAILROAD MEDICARE
MS01537007Medicaid