Provider Demographics
NPI:1750513818
Name:MAGNOLIA ADDICTION TREATMENT SERVICES
Entity type:Organization
Organization Name:MAGNOLIA ADDICTION TREATMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:W
Authorized Official - Last Name:TROSCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-905-2965
Mailing Address - Street 1:500 E WOODROW WILSON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E WOODROW WILSON AVE STE D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-896-0349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty