1205486859 NPI number — MAGNOLIA MANOR OF LIBERTY COUNTY, INC.

Table of content: CLAIRE CONERLY MADDEN CIT (NPI 1316457971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205486859 NPI number — MAGNOLIA MANOR OF LIBERTY COUNTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA MANOR OF LIBERTY COUNTY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205486859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 S LEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMERICUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31709-4715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-924-9352
Provider Business Mailing Address Fax Number:
229-931-5999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 N COASTAL HWY # 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDWAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31320-3433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-884-3361
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ADKINS
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
DANNY
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
229-931-5907

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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