1205380920 NPI number — MAGNOLIA ABA INSTITUTE, INC

Table of content: (NPI 1205380920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205380920 NPI number — MAGNOLIA ABA INSTITUTE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA ABA INSTITUTE, 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:
1205380920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7944 PRINCETON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34104-6667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-613-1869
Provider Business Mailing Address Fax Number:
931-443-0203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
279 CLEAR SKY CT
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37043-5946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-613-1869
Provider Business Practice Location Address Fax Number:
931-443-0203
Provider Enumeration Date:
08/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
615-613-1869

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  000856685 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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