Provider Demographics
NPI:1801340856
Name:MAGNOLIA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:MAGNOLIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-453-2341
Mailing Address - Street 1:946 HARMONY RD STE B
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-5877
Mailing Address - Country:US
Mailing Address - Phone:706-991-5320
Mailing Address - Fax:866-720-5313
Practice Address - Street 1:946 HARMONY RD
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-5877
Practice Address - Country:US
Practice Address - Phone:706-991-5320
Practice Address - Fax:866-720-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GAME53031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty