Provider Demographics
NPI:1538204094
Name:MAGNOLIA MANOR AT TUPELO
Entity type:Organization
Organization Name:MAGNOLIA MANOR AT TUPELO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-842-6776
Mailing Address - Street 1:5427A FAIN LN
Mailing Address - Street 2:
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-9214
Mailing Address - Country:US
Mailing Address - Phone:662-397-2733
Mailing Address - Fax:
Practice Address - Street 1:5427A FAIN LN
Practice Address - Street 2:
Practice Address - City:BELDEN
Practice Address - State:MS
Practice Address - Zip Code:38826-9214
Practice Address - Country:US
Practice Address - Phone:662-397-2733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1000302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03083202Medicaid