Provider Demographics
NPI:1427448679
Name:SOUTHERN MAGNOLIA PERSONAL CARE HOME
Entity type:Organization
Organization Name:SOUTHERN MAGNOLIA PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAE
Authorized Official - Middle Name:LOIS
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-2379
Mailing Address - Street 1:405 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-3120
Mailing Address - Country:US
Mailing Address - Phone:912-537-2379
Mailing Address - Fax:912-537-7040
Practice Address - Street 1:405 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3120
Practice Address - Country:US
Practice Address - Phone:912-537-2379
Practice Address - Fax:912-537-7040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA442827106A305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service