Provider Demographics
NPI:1013337286
Name:FIVE MAGNOLIAS ASSISTED LIVING
Entity Type:Organization
Organization Name:FIVE MAGNOLIAS ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:813-486-0702
Mailing Address - Street 1:6116 AUDUBON MANOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-5031
Mailing Address - Country:US
Mailing Address - Phone:813-486-0702
Mailing Address - Fax:813-315-8965
Practice Address - Street 1:6116 AUDUBON MANOR BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-5031
Practice Address - Country:US
Practice Address - Phone:813-486-0702
Practice Address - Fax:813-315-8965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL124573104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness