Basic Information
| Provider Information | |||||||||
| NPI: | 1164510475 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AUTUMN LEAVES NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40018 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708350018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257530864 | ||||||||
| FaxNumber: | 2257530948 | ||||||||
| Practice Location | |||||||||
| Address1: | 570 SOLOMON ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387032771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623355863 | ||||||||
| FaxNumber: | 6623355874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | DASPIT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2259064644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | SR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 494 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 220307 | 05 | MS | MEDICAID |