Basic Information
| Provider Information | |||||||||
| NPI: | 1659353688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREFERRED CARE DEVELOPMENTAL CENTERS OF MS I INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CANTON MANOR | ||||||||
| 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: | 1145 TISDALE AVE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390464965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018596712 | ||||||||
| FaxNumber: | 6018592355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLLIER | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | LATTURE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9729313800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 630 | MS | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 00220054 | 05 | MS | MEDICAID |