Provider Demographics
NPI:1891228581
Name:MAGNOLIA GARDENS ASSISTED LIVING
Entity Type:Organization
Organization Name:MAGNOLIA GARDENS ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN/VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-477-9041
Mailing Address - Street 1:303 E IVY ST
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-2746
Mailing Address - Country:US
Mailing Address - Phone:601-477-9041
Mailing Address - Fax:601-477-9006
Practice Address - Street 1:303 EAST IVY
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437
Practice Address - Country:US
Practice Address - Phone:601-477-9041
Practice Address - Fax:601-477-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1059310400000X, 3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility