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General NPI Number Information
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NPI Number | 1851819585
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Entity Type | Organization
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Legal Business Name | SUPERIOR PRO-CARE HOME PROVIDER
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Dates
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Enumeration Date | 09/01/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1421 DALTON ST
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City | JACKSON
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State | MS
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Zip | 39204-2806
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Country | US
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Telephone | 769-447-5458
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Fax | 769-447-5451
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Provider Business Mailing Address
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Address Line | 1421 DALTON ST
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City | JACKSON
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State | MS
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Zip | 39204-2806
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Country | US
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Telephone | 769-447-5458
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Fax | 769-447-5451
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Authorized Official
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Title or Position | PROVIDER
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Name | MRS. PATRICIA T CLAYTON
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Credential | EXECUTIVE MANAGER
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Telephone | 769-447-5458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | MS
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