Basic Information
| Provider Information | |||||||||
| NPI: | 1972839777 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNOLIA HEALTH SYSTEMS XI | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AZALEA HILLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9455 DELEGATES ROW | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462403805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178181240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3700 LAFAYETTE PKWY | ||||||||
| Address2: | |||||||||
| City: | FLOYDS KNOBS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471199788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129234888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2009 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3178181240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 09-012161-1 | 01 | IN | STATE LICENSE | OTHER |