Provider Demographics
NPI:1447687637
Name:MAGNOLIA MANOR OF PALM COAST, INC.
Entity type:Organization
Organization Name:MAGNOLIA MANOR OF PALM COAST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:MARZAN
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-214-6176
Mailing Address - Street 1:35 BURNING SANDS LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8808
Mailing Address - Country:US
Mailing Address - Phone:386-447-8562
Mailing Address - Fax:386-447-8563
Practice Address - Street 1:35 BURNING SANDS LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8808
Practice Address - Country:US
Practice Address - Phone:386-447-8562
Practice Address - Fax:386-447-8563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9708310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility