Provider Demographics
NPI:1952695256
Name:SPECIALTY HEALTHCARE
Entity Type:Organization
Organization Name:SPECIALTY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAKEYLA
Authorized Official - Middle Name:SHARELLE
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-613-2666
Mailing Address - Street 1:16 LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154
Mailing Address - Country:US
Mailing Address - Phone:601-613-2666
Mailing Address - Fax:601-857-0075
Practice Address - Street 1:16 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-7614
Practice Address - Country:US
Practice Address - Phone:601-613-2666
Practice Address - Fax:601-857-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP317056164W00000X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251J00000XAgenciesNursing Care
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty