Basic Information
| Provider Information | |||||||||
| NPI: | 1396169074 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA HOSPICE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPUSCARE OF GEORGIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 SW 80TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055911606 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1374 MANCHESTER DR NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704839111 | ||||||||
| FaxNumber: | 8776638423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2014 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROQUE-VELASCO | ||||||||
| AuthorizedOfficialFirstName: | ISMAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3055911606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | N | Agencies | Hospice Care, Community Based | 315D00000X | 122-0392-H | GA | Y | Nursing & Custodial Care Facilities | Hospice, Inpatient |
No ID Information.