Provider Demographics
NPI:1306630801
Name:MAGNOLIA COMFORT MEDICAL SOUTH LLC
Entity type:Organization
Organization Name:MAGNOLIA COMFORT MEDICAL SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-268-8891
Mailing Address - Street 1:7193 JONESBORO RD STE 101-102
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2961
Mailing Address - Country:US
Mailing Address - Phone:470-726-1699
Mailing Address - Fax:
Practice Address - Street 1:7193 JONESBORO RD STE 101-102
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2961
Practice Address - Country:US
Practice Address - Phone:470-726-1699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty