Provider Demographics
NPI:1245434109
Name:MAGNOLIA HOUSE L.P.
Entity type:Organization
Organization Name:MAGNOLIA HOUSE L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:DIRK
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-824-9010
Mailing Address - Street 1:106A OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2404
Mailing Address - Country:US
Mailing Address - Phone:601-824-9010
Mailing Address - Fax:601-824-9044
Practice Address - Street 1:311 HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4635
Practice Address - Country:US
Practice Address - Phone:601-446-5097
Practice Address - Fax:601-442-5930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS672310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility