Basic Information
| Provider Information | |||||||||
| NPI: | 1811579758 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAGNOLIA BRIDGE HOME AND HEALTH LLC | ||||||||
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| OtherOrganizationName: | MAGNOLIA BRIDGE HOME AND HEALTH LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 REALINI DR | ||||||||
| Address2: | |||||||||
| City: | HAVELOCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285329403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526658819 | ||||||||
| FaxNumber: | 2522542705 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 REALINI DR | ||||||||
| Address2: | |||||||||
| City: | HAVELOCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285329403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526658819 | ||||||||
| FaxNumber: | 2522542705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2526658819 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR/L | ||||||||
| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 251S00000X | N | Agencies | Community/Behavioral Health | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.