Provider Demographics
NPI:1750306569
Name:MAGNOLIA AMBULANCE SERVICE
Entity type:Organization
Organization Name:MAGNOLIA AMBULANCE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-379-6261
Mailing Address - Street 1:1129 BRETT DR SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5998
Mailing Address - Country:US
Mailing Address - Phone:770-761-7608
Mailing Address - Fax:770-761-4078
Practice Address - Street 1:1129 BRETT DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5998
Practice Address - Country:US
Practice Address - Phone:770-761-7608
Practice Address - Fax:770-761-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA122-053416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA59RCBNPMedicare ID - Type Unspecified