Provider Demographics
NPI:1649489949
Name:MAGNOLIA MANOR, INC.
Entity type:Organization
Organization Name:MAGNOLIA MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-442-3633
Mailing Address - Street 1:RR 2 BOX 265C
Mailing Address - Street 2:
Mailing Address - City:PURDY
Mailing Address - State:MO
Mailing Address - Zip Code:65734-9507
Mailing Address - Country:US
Mailing Address - Phone:417-442-3633
Mailing Address - Fax:417-442-3635
Practice Address - Street 1:RR 2 BOX 265C
Practice Address - Street 2:
Practice Address - City:PURDY
Practice Address - State:MO
Practice Address - Zip Code:65734-9507
Practice Address - Country:US
Practice Address - Phone:417-442-3633
Practice Address - Fax:417-442-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032816310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility