Provider Demographics
NPI:1831316439
Name:MAGNOLIA PLACE, INC.
Entity Type:Organization
Organization Name:MAGNOLIA PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:SHINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-436-7448
Mailing Address - Street 1:P.O. BOX 663
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-0663
Mailing Address - Country:US
Mailing Address - Phone:229-436-7448
Mailing Address - Fax:229-883-2777
Practice Address - Street 1:6430 NEWTON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-5627
Practice Address - Country:US
Practice Address - Phone:229-436-7448
Practice Address - Fax:229-883-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility