Provider Demographics
NPI:1790926855
Name:MAGNOLIA HEALTH CENTER
Entity Type:Organization
Organization Name:MAGNOLIA HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:T
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-234-8800
Mailing Address - Street 1:205 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-3518
Mailing Address - Country:US
Mailing Address - Phone:870-234-8800
Mailing Address - Fax:870-234-8801
Practice Address - Street 1:205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3518
Practice Address - Country:US
Practice Address - Phone:870-234-8800
Practice Address - Fax:870-234-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR15693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1386647774OtherINDIVIDUAL NPI
AR5605574OtherAETNA