Provider Demographics
NPI:1376356311
Name:MAGNOLIA JED PROUTY
Entity type:Organization
Organization Name:MAGNOLIA JED PROUTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-702-0144
Mailing Address - Street 1:175 EXCHANGE ST STE 240
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-7408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-4115
Practice Address - Country:US
Practice Address - Phone:207-902-1220
Practice Address - Fax:207-902-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility