1477566024 NPI number — MAGNOLIA SPECIAL CARE CENTER INC

Table of content: (NPI 1477566024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477566024 NPI number — MAGNOLIA SPECIAL CARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA SPECIAL CARE CENTER 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:
SHEA FAMILY CARE MAGNOLIA
Provider Other Organization Name Type Code:
3
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:
1477566024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 S MAGNOLIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92020-6012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-442-8826
Provider Business Mailing Address Fax Number:
619-442-0288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
635 S MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92020-6012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-442-8826
Provider Business Practice Location Address Fax Number:
619-442-0288
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
PATRICIA
Authorized Official Title or Position:
CHIEF LEGAL COUNSEL
Authorized Official Telephone Number:
619-441-8771

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  090000072 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZT05890J , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com