Provider Demographics
NPI:1851819585
Name:SUPERIOR PRO-CARE HOME PROVIDER
Entity Type:Organization
Organization Name:SUPERIOR PRO-CARE HOME PROVIDER
Other - Org Name:SUPERIOR PRO CARE HOME PROVIDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE MANAGER
Authorized Official - Phone:769-447-5458
Mailing Address - Street 1:1421 DALTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2806
Mailing Address - Country:US
Mailing Address - Phone:769-447-5458
Mailing Address - Fax:769-447-5451
Practice Address - Street 1:1421 DALTON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2806
Practice Address - Country:US
Practice Address - Phone:769-447-5458
Practice Address - Fax:769-447-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherPRIVATE DUTY
MS=========Medicaid