Provider Demographics
NPI:1891737573
Name:MAGNOLIA GARDENS LLC
Entity Type:Organization
Organization Name:MAGNOLIA GARDENS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:6710 MALLERY DR
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3964
Mailing Address - Country:US
Mailing Address - Phone:301-552-2000
Mailing Address - Fax:
Practice Address - Street 1:6710 MALLERY DR
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3964
Practice Address - Country:US
Practice Address - Phone:301-552-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16011235Z00000X
MD16-011314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
345178OtherUNITED - MAMSI
7100074OtherUNITED - AMERICHOICE
HV1OtherCAREFIRST BLUECHOICE
028FOtherCAREFIRST PROV/INQ#
08952OtherAMERIGROUP
0529622OtherAENTA-HMO
MD818989700Medicaid
HV1OtherCAREFIRST IND/PPO
=========OtherNATIONAL CAPITAL PPO
HV1OtherCAREFIRST IND/PPO
7100074OtherUNITED - AMERICHOICE
=========OtherCOVENTRY
=========OtherJOHNS HOPKINS
=========OtherKAISER
08952OtherAMERIGROUP
=========OtherHNFS-TRICARE
=========OtherHELIXCARE (MEDSTAR)
MD818989700Medicaid