Provider Demographics
NPI:1003784471
Name:SWEETBAY MAGNOLIA SHARED LIVING LLC
Entity type:Organization
Organization Name:SWEETBAY MAGNOLIA SHARED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:INEZ
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-518-8991
Mailing Address - Street 1:42639 REMINISCENT LN STE B
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-7558
Mailing Address - Country:US
Mailing Address - Phone:314-518-8991
Mailing Address - Fax:205-651-8099
Practice Address - Street 1:42639 REMINISCENT LN
Practice Address - Street 2:STE B
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354
Practice Address - Country:US
Practice Address - Phone:314-518-8991
Practice Address - Fax:205-651-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-28
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty