Provider Demographics
NPI:1396169074
Name:MAGNOLIA HOSPICE, LLC
Entity type:Organization
Organization Name:MAGNOLIA HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE-VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-591-1606
Mailing Address - Street 1:6900 SW 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4931
Mailing Address - Country:US
Mailing Address - Phone:305-591-1606
Mailing Address - Fax:
Practice Address - Street 1:1374 MANCHESTER DR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3881
Practice Address - Country:US
Practice Address - Phone:770-483-9111
Practice Address - Fax:877-663-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
GA122-0392-H315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA251G00000XMedicare UPIN