1275650160 NPI number — MAGNOLIA ASSOCIATES OF AUGUSTA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275650160 NPI number — MAGNOLIA ASSOCIATES OF AUGUSTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA ASSOCIATES OF AUGUSTA
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:
1275650160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 PITCARIN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-5767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-364-8430
Provider Business Mailing Address Fax Number:
706-364-8431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3643 WALTON WAY EXT
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-4507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-364-8430
Provider Business Practice Location Address Fax Number:
706-364-8431
Provider Enumeration Date:
03/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAMP
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
706-364-8430

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC 2673 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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