Provider Demographics
NPI:1649883018
Name:MAGNOLIA CANAL WINCHESTER LLC
Entity type:Organization
Organization Name:MAGNOLIA CANAL WINCHESTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-203-1163
Mailing Address - Street 1:6160 GENDER RD
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-2054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6160 GENDER RD
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-2054
Practice Address - Country:US
Practice Address - Phone:614-591-3522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty