Provider Demographics
NPI:1225886393
Name:MAGNOLIA MEMORY CARE, INC.
Entity type:Organization
Organization Name:MAGNOLIA MEMORY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BILL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CDP
Authorized Official - Phone:704-840-2509
Mailing Address - Street 1:2764 PLEASANT ROAD PMB 876
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708
Mailing Address - Country:US
Mailing Address - Phone:704-840-2509
Mailing Address - Fax:
Practice Address - Street 1:1190 GOLD HILL RD
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8977
Practice Address - Country:US
Practice Address - Phone:803-548-4078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management