Basic Information
| Provider Information | |||||||||
| NPI: | 1427030253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA PREFERRED CARE DEVELOPMENTAL CENTERS I, INC. | ||||||||
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| OtherOrganizationName: | SANDY PARK DEVELOPMENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5420 W PLANO PKWY | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750934823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729313800 | ||||||||
| FaxNumber: | 9727676222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2975 GARDEN ST | ||||||||
| Address2: | |||||||||
| City: | N FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339171883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399955833 | ||||||||
| FaxNumber: | 2399954856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 07/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | COLLIER | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | LATTURE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9729313800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 4071095 | FL | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 028000300 | 05 | FL | MEDICAID |