Provider Demographics
NPI:1053519579
Name:MAGNOLIA HOUSE PCH, INC
Entity type:Organization
Organization Name:MAGNOLIA HOUSE PCH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:912-384-3377
Mailing Address - Street 1:221 COLLEGE AVE S
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2303
Mailing Address - Country:US
Mailing Address - Phone:912-384-3377
Mailing Address - Fax:
Practice Address - Street 1:221 COLLEGE AVE S
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2303
Practice Address - Country:US
Practice Address - Phone:912-384-3377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities