Provider Demographics
NPI:1871050054
Name:MAGNOLIA HOSPICE OF MACON, LLC
Entity type:Organization
Organization Name:MAGNOLIA HOSPICE OF MACON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE-VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-591-1606
Mailing Address - Street 1:6900 SW 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4931
Mailing Address - Country:US
Mailing Address - Phone:305-591-1606
Mailing Address - Fax:305-591-1618
Practice Address - Street 1:1515 BASS RD STE G
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-7579
Practice Address - Country:US
Practice Address - Phone:470-281-8686
Practice Address - Fax:877-663-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient