Healthcare Provider Details

I. General information

NPI: 1831147677
Provider Name (Legal Business Name): DESOTO COMMUNITY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3068 NAIL RD W
HORN LAKE MS
38637-3002
US

IV. Provider business mailing address

3068 NAIL RD W
HORN LAKE MS
38637-3002
US

V. Phone/Fax

Practice location:
  • Phone: 662-280-1219
  • Fax: 662-280-4668
Mailing address:
  • Phone: 662-280-1219
  • Fax: 662-280-4668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number943
License Number StateMS

VIII. Authorized Official

Name: MRS. TONI PARKINSON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 601-709-1408