Organization Name: | MAGNOLIA COMPREHENSIVE OUTPATIENT REHABILIATION FACILITY INC. |
NPI Number: | 1407853716 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | DEWARRENT LEE BRANTLEY (CEO/PRESIDENT) |
Mailing Address: | 2005 Creswell Ave Shreveport |
State: | LA US |
Postal Code: | 711042201 |
Phone Number: | 3186760705 |
Fax Number: | 3186760709 |
NPI Enumeration Date: | 06/30/2005 |
NPI Last Update Date: | 08/18/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QR0401X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
Taxonomy Definition: |