Provider Demographics
NPI:1851700363
Name:MAGNOLIA PHYSICIAN SERVICES PLLC
Entity Type:Organization
Organization Name:MAGNOLIA PHYSICIAN SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:SALDANA
Authorized Official - Last Name:FALCON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:281-713-8381
Mailing Address - Street 1:PO BOX 6141
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77325-6141
Mailing Address - Country:US
Mailing Address - Phone:281-713-8381
Mailing Address - Fax:
Practice Address - Street 1:770 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:NEW CANEY
Practice Address - State:TX
Practice Address - Zip Code:77357-3324
Practice Address - Country:US
Practice Address - Phone:281-713-8381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF58051Medicare UPIN