Provider Demographics
NPI:1053913442
Name:MAGNOLIA PEC, LLC
Entity type:Organization
Organization Name:MAGNOLIA PEC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-323-1930
Mailing Address - Street 1:PO BOX 2403
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207
Mailing Address - Country:US
Mailing Address - Phone:318-323-1930
Mailing Address - Fax:318-323-1013
Practice Address - Street 1:404 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-3876
Practice Address - Country:US
Practice Address - Phone:601-682-1250
Practice Address - Fax:601-682-1256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-11
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS007828091Medicaid