Provider Demographics
NPI:1396780987
Name:MAGNIFIQUE, INC.
Entity type:Organization
Organization Name:MAGNIFIQUE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:870-534-2224
Mailing Address - Street 1:730 S BLAKE ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-1822
Mailing Address - Country:US
Mailing Address - Phone:870-534-2224
Mailing Address - Fax:870-534-1226
Practice Address - Street 1:730 S BLAKE ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-1822
Practice Address - Country:US
Practice Address - Phone:870-534-2224
Practice Address - Fax:870-534-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5695680001Medicare NSC