Provider Demographics
NPI:1427761261
Name:MAGNOLIA CARE HOME 1 LLC
Entity type:Organization
Organization Name:MAGNOLIA CARE HOME 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:GBATY
Authorized Official - Last Name:SOUMAHORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-409-7096
Mailing Address - Street 1:4727 SONGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6228
Mailing Address - Country:US
Mailing Address - Phone:510-409-7096
Mailing Address - Fax:
Practice Address - Street 1:4727 SONGWOOD CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-6228
Practice Address - Country:US
Practice Address - Phone:510-409-7096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility