Provider Demographics
NPI:1851083919
Name:MAGNOLIA OUTPATIENT PHYSICAL THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:MAGNOLIA OUTPATIENT PHYSICAL THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:SEDACCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-557-1074
Mailing Address - Street 1:24 MARTIN LN
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6099
Mailing Address - Country:US
Mailing Address - Phone:214-828-6146
Mailing Address - Fax:
Practice Address - Street 1:24 MARTIN LN
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6099
Practice Address - Country:US
Practice Address - Phone:207-930-7037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty