Provider Demographics
NPI:1902139033
Name:MAGNOLIA CLUBHOUSE INC
Entity Type:Organization
Organization Name:MAGNOLIA CLUBHOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:216-721-3030
Mailing Address - Street 1:11101 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1813
Mailing Address - Country:US
Mailing Address - Phone:216-721-3030
Mailing Address - Fax:216-721-0105
Practice Address - Street 1:11101 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1813
Practice Address - Country:US
Practice Address - Phone:216-721-3030
Practice Address - Fax:216-721-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health