Provider Demographics
NPI:1871310425
Name:MAGNOLIA MANOR LLC
Entity type:Organization
Organization Name:MAGNOLIA MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIUTAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-348-1789
Mailing Address - Street 1:14221 N 136TH LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8453
Mailing Address - Country:US
Mailing Address - Phone:602-348-1789
Mailing Address - Fax:623-292-5977
Practice Address - Street 1:14221 N 136TH LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-8453
Practice Address - Country:US
Practice Address - Phone:602-348-1789
Practice Address - Fax:623-292-5977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility