Provider Demographics
NPI:1871392860
Name:MAGNOLIA FAMILY WELLNESS CLINIC
Entity type:Organization
Organization Name:MAGNOLIA FAMILY WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:KEMP
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:601-466-2056
Mailing Address - Street 1:5056 W 4TH ST # 100
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1069
Mailing Address - Country:US
Mailing Address - Phone:601-410-6525
Mailing Address - Fax:
Practice Address - Street 1:5056 W 4TH ST # 100
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1069
Practice Address - Country:US
Practice Address - Phone:601-410-6525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-11
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical