Basic Information
| Provider Information | |||||||||
| NPI: | 1871050054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA HOSPICE OF MACON, 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: | 3055911618 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 ARKWRIGHT LNDG | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312101364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702818686 | ||||||||
| FaxNumber: | 8776638423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2019 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROQUE-VELASCO | ||||||||
| AuthorizedOfficialFirstName: | ISMAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3055911606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | N | Nursing & Custodial Care Facilities | Hospice, Inpatient | 251G00000X | Y | Agencies | Hospice Care, Community Based |
No ID Information.