Provider Demographics
NPI:1659353688
Name:PREFERRED CARE DEVELOPMENTAL CENTERS OF MS I INC
Entity Type:Organization
Organization Name:PREFERRED CARE DEVELOPMENTAL CENTERS OF MS I INC
Other - Org Name:CANTON MANOR
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:972-931-3800
Mailing Address - Street 1:5420 W PLANO PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4823
Mailing Address - Country:US
Mailing Address - Phone:972-931-3800
Mailing Address - Fax:972-767-6222
Practice Address - Street 1:1145 TISDALE AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4965
Practice Address - Country:US
Practice Address - Phone:601-859-6712
Practice Address - Fax:601-859-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS630315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00220054Medicaid