Provider Demographics
NPI:1154783660
Name:MAGNOLIA MANOR
Entity type:Organization
Organization Name:MAGNOLIA MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:BEBIE
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-217-3908
Mailing Address - Street 1:387 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-9407
Mailing Address - Country:US
Mailing Address - Phone:707-433-9705
Mailing Address - Fax:707-473-0161
Practice Address - Street 1:387 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-9407
Practice Address - Country:US
Practice Address - Phone:707-433-9705
Practice Address - Fax:707-473-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496801129310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility