Provider Demographics
NPI:1689374589
Name:MAGNOLIA MOBILE HOME CARE LLC
Entity Type:Organization
Organization Name:MAGNOLIA MOBILE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONDER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:662-315-5612
Mailing Address - Street 1:300 FRONT ST S STE 6
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-4202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 FRONT ST S STE 6
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-4202
Practice Address - Country:US
Practice Address - Phone:662-315-5612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care