Provider Demographics
NPI:1700214400
Name:MAGNOLIA MANOR SENIOR DAY PROGRAM, LLC
Entity Type:Organization
Organization Name:MAGNOLIA MANOR SENIOR DAY PROGRAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:O'NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:850-362-6556
Mailing Address - Street 1:141 BARKS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6774
Mailing Address - Country:US
Mailing Address - Phone:850-225-2985
Mailing Address - Fax:
Practice Address - Street 1:141 BARKS DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6774
Practice Address - Country:US
Practice Address - Phone:850-225-2985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000706400Medicaid