Provider Demographics
NPI:1760677413
Name:MAGNOLIA GARDENS
Entity Type:Organization
Organization Name:MAGNOLIA GARDENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:YARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-983-7635
Mailing Address - Street 1:594 MURRAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7016
Mailing Address - Country:US
Mailing Address - Phone:910-692-6311
Mailing Address - Fax:
Practice Address - Street 1:594 MURRAY HILL RD
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387
Practice Address - Country:US
Practice Address - Phone:910-692-6311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-063-007310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802822OtherMEDICAID PROVIDER NUMBER