Organization
MAGNOLIA PEC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELIZABETH BRISTER (OWNER)
(318) 323-1930
Entity
Organization
Contact information
Practice address
404 N 12TH AVE, LAUREL, MS 39440-3876
(601) 682-1250
(601) 682-1256
Mailing address
PO BOX 2403, MONROE, LA 71207
(318) 323-1930
(318) 323-1013
Taxonomy
Speciality
Code
Description
License number
State
261QM3000X
Medically Fragile Infants and Children Day Care
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007828091
—
MS
Enumeration date
11/11/2020
Last updated
02/28/2023
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