Provider Demographics
NPI:1770375768
Name:MAGNOLIA DIAGNOSTIC SERVICES INC.
Entity type:Organization
Organization Name:MAGNOLIA DIAGNOSTIC SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWARRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-840-9074
Mailing Address - Street 1:4005 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-1927
Mailing Address - Country:US
Mailing Address - Phone:318-840-9074
Mailing Address - Fax:
Practice Address - Street 1:4005 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-1927
Practice Address - Country:US
Practice Address - Phone:318-840-9074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-19
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty