Provider Demographics
NPI:1154966463
Name:BLUE MAGNOLIA PLACE, LLC
Entity type:Organization
Organization Name:BLUE MAGNOLIA PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-703-7406
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32704-1029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2218 PALMETUM LOOP
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-6066
Practice Address - Country:US
Practice Address - Phone:407-703-7406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health