Provider Demographics
NPI:1831429158
Name:MAGNOLIA HAVEN NURSING HOME, LLC
Entity type:Organization
Organization Name:MAGNOLIA HAVEN NURSING HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:OIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-727-4960
Mailing Address - Street 1:602 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:TUSKEGEE
Mailing Address - State:AL
Mailing Address - Zip Code:36083-7274
Mailing Address - Country:US
Mailing Address - Phone:334-727-4960
Mailing Address - Fax:
Practice Address - Street 1:602 AUBURN ST
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-7274
Practice Address - Country:US
Practice Address - Phone:334-727-4960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA HAVEN NURSING HOME, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-08
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR4401261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)