Provider Demographics
NPI:1285060681
Name:MAGNOLIA MEDICAL, LLC
Entity type:Organization
Organization Name:MAGNOLIA MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-763-1314
Mailing Address - Street 1:304 HIGHLAND BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4624
Mailing Address - Country:US
Mailing Address - Phone:601-442-6493
Mailing Address - Fax:601-442-0999
Practice Address - Street 1:400 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3307
Practice Address - Country:US
Practice Address - Phone:318-336-6088
Practice Address - Fax:318-336-6095
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA MEDICAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4726240001Medicare NSC