Organization
MAGNOLIA COMPREHENSIVE OUTPATIENT REHABILIATION FACILITY INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DEWARRENT LEE BRANTLEY (CEO/PRESIDENT)
(318) 676-0705
Entity
Organization
Contact information
Practice address
2005 CRESWELL AVE, SHREVEPORT, LA 71104-2201
(318) 676-0705
(318) 676-0709
Mailing address
2005 CRESWELL AVE, SHREVEPORT, LA 71104-2201
(318) 676-0705
(318) 676-0709
Taxonomy
Speciality
Code
Description
License number
State
261QR0401X
Comprehensive Outpatient Rehabilitation Facility (CORF)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1159310
—
LA
Enumeration date
06/30/2005
Last updated
08/18/2011
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