Provider Demographics
NPI:1518704220
Name:MAGNOLIA GRACE SENIOR CARE OF GEORGIA, LLC
Entity type:Organization
Organization Name:MAGNOLIA GRACE SENIOR CARE OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DINITRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:WRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-855-5114
Mailing Address - Street 1:1201 SHADOWLAWN DR STE 115
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4074
Mailing Address - Country:US
Mailing Address - Phone:912-266-8737
Mailing Address - Fax:912-228-3400
Practice Address - Street 1:501 GLOUCESTER ST STE 115
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7030
Practice Address - Country:US
Practice Address - Phone:912-266-8737
Practice Address - Fax:912-228-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-10
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care