Provider Demographics
NPI:1801078951
Name:SWEET MAGNOLIA MOON, A SLEEP CENTER, LLC
Entity type:Organization
Organization Name:SWEET MAGNOLIA MOON, A SLEEP CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-268-5222
Mailing Address - Street 1:6026 U S HIGHWAY 98
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8861
Mailing Address - Country:US
Mailing Address - Phone:601-268-5222
Mailing Address - Fax:601-296-3508
Practice Address - Street 1:6026 U S HIGHWAY 98
Practice Address - Street 2:SUITE 3
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8861
Practice Address - Country:US
Practice Address - Phone:601-268-5222
Practice Address - Fax:601-296-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic