Provider Demographics
NPI:1811786825
Name:MAGNOLIA CONGREGATE LIVING INC
Entity type:Organization
Organization Name:MAGNOLIA CONGREGATE LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNO
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:CORNEJO
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:562-301-8792
Mailing Address - Street 1:4042 WINTERHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-1647
Mailing Address - Country:US
Mailing Address - Phone:562-301-8792
Mailing Address - Fax:
Practice Address - Street 1:1572 EVERGREEN LN
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3010
Practice Address - Country:US
Practice Address - Phone:562-301-8792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty