Provider Demographics
NPI:1245278365
Name:MAGNOLIA HEALTHCARE CENTER PA
Entity type:Organization
Organization Name:MAGNOLIA HEALTHCARE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:TERRASSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-356-2525
Mailing Address - Street 1:18602 FM 1488 RD
Mailing Address - Street 2:STE 700
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-8508
Mailing Address - Country:US
Mailing Address - Phone:281-356-2525
Mailing Address - Fax:281-356-2920
Practice Address - Street 1:18602 FM 1488 RD
Practice Address - Street 2:STE 700
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-8508
Practice Address - Country:US
Practice Address - Phone:281-356-2525
Practice Address - Fax:281-356-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177777301Medicaid
TX177777301Medicaid