Basic Information
| Provider Information | |||||||||
| NPI: | 1508982455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAGNOLIA FAMILY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1418 TIGER DR | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854494055 | ||||||||
| FaxNumber: | 9854494178 | ||||||||
| Practice Location | |||||||||
| Address1: | 1418 TIGER DR | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854494055 | ||||||||
| FaxNumber: | 9854494178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | OLIVIER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9854494055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1176621 | LA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 600720425 | 01 | LA | MAGELLAN HEALTH SERVICES | OTHER | 1176621 | 05 | LA | MEDICAID |