Provider Demographics
NPI:1922307586
Name:MAGNOLIA RETIREMENT HOME INC
Entity Type:Organization
Organization Name:MAGNOLIA RETIREMENT HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOMISIW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-382-2116
Mailing Address - Street 1:149 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-3613
Mailing Address - Country:US
Mailing Address - Phone:863-382-2116
Mailing Address - Fax:863-382-2117
Practice Address - Street 1:149 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-3613
Practice Address - Country:US
Practice Address - Phone:863-382-2116
Practice Address - Fax:863-382-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4947310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140646900Medicaid