Provider Demographics
NPI:1881691194
Name:MAGNOLIA REHABILITATION SERVICES INC
Entity type:Organization
Organization Name:MAGNOLIA REHABILITATION SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWARRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-840-9074
Mailing Address - Street 1:4005 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-1927
Mailing Address - Country:US
Mailing Address - Phone:318-840-9074
Mailing Address - Fax:318-860-3025
Practice Address - Street 1:4005 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-1927
Practice Address - Country:US
Practice Address - Phone:337-324-8465
Practice Address - Fax:318-676-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
LA5CF64261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CF64Medicare ID - Type UnspecifiedARKANSASBLUECROSS&BLUESHE
LA51444CF64Medicare UPIN