Provider Demographics
NPI:1043323934
Name:FLORIDA PREFERRED CARE DEVELOPMENTAL CENTERS I, INC
Entity Type:Organization
Organization Name:FLORIDA PREFERRED CARE DEVELOPMENTAL CENTERS I, INC
Other - Org Name:SANDY PARK DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LATTURE
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-607-7195
Mailing Address - Street 1:751 AVIGNON DR
Mailing Address - Street 2:SUITE I
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5161
Mailing Address - Country:US
Mailing Address - Phone:601-607-7195
Mailing Address - Fax:601-607-7196
Practice Address - Street 1:2975 GARDEN ST
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33917-1883
Practice Address - Country:US
Practice Address - Phone:239-995-5833
Practice Address - Fax:239-995-4856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4071095315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities