Provider Demographics
NPI:1154940906
Name:MAGNOLIA COMFORT MEDICAL LLC
Entity type:Organization
Organization Name:MAGNOLIA COMFORT MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:470-545-0275
Mailing Address - Street 1:4935 JIMMY CARTER BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3536
Mailing Address - Country:US
Mailing Address - Phone:470-545-0275
Mailing Address - Fax:
Practice Address - Street 1:4935 JIMMY CARTER BLVD STE 360
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3536
Practice Address - Country:US
Practice Address - Phone:470-545-0275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-12
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty