1174505010 NPI number — PREFERRED CARE DEVELOPMENTAL CENTERS OF MS I INC

Table of content: (NPI 1174505010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174505010 NPI number — PREFERRED CARE DEVELOPMENTAL CENTERS OF MS I INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED CARE DEVELOPMENTAL CENTERS OF MS I INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LINCOLN RESIDENTIAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174505010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5420 W PLANO PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-4823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-931-3800
Provider Business Mailing Address Fax Number:
972-767-6222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
524 BROOKMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39601-2384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-835-1884
Provider Business Practice Location Address Fax Number:
601-833-0430
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLLIER
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
LATTURE
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
972-931-3800

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  629 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00220055 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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