Provider Demographics
NPI:1841027646
Name:MAGNOLIA PEDIATRIC CLINIC
Entity type:Organization
Organization Name:MAGNOLIA PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:REECE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-293-7678
Mailing Address - Street 1:401 ALCORN DR STE 2C
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9073
Mailing Address - Country:US
Mailing Address - Phone:662-293-1288
Mailing Address - Fax:662-293-4358
Practice Address - Street 1:401 ALCORN DR STE 1B
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9071
Practice Address - Country:US
Practice Address - Phone:662-293-7390
Practice Address - Fax:662-293-7399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health