Provider Demographics
NPI:1699513598
Name:MAGNOLIA MED SPA AND IV THERAPY INC.
Entity type:Organization
Organization Name:MAGNOLIA MED SPA AND IV THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:580-615-0000
Mailing Address - Street 1:3008 W UNIVERSITY BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2927
Mailing Address - Country:US
Mailing Address - Phone:580-615-0000
Mailing Address - Fax:580-615-0001
Practice Address - Street 1:3008 W UNIVERSITY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2927
Practice Address - Country:US
Practice Address - Phone:580-615-0000
Practice Address - Fax:580-615-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty