Provider Demographics
NPI:1518483239
Name:MAGNOLIA GARDENS LLC
Entity type:Organization
Organization Name:MAGNOLIA GARDENS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:6710 MALLERY DR
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3964
Mailing Address - Country:US
Mailing Address - Phone:301-552-2000
Mailing Address - Fax:301-552-2001
Practice Address - Street 1:6710 MALLERY DR
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3964
Practice Address - Country:US
Practice Address - Phone:301-552-2000
Practice Address - Fax:301-552-2001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGNOLIA JV LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility