MEDICARE: FLORIDA PREFERRED CARE DEVELOPMENTAL CENTERS I, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	4071095	FL

General Provider Information

NPI Number	:	1043323934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA PREFERRED CARE DEVELOPMENTAL CENTERS I, INC

Provider Business Mailing Address
First Line	:	751 AVIGNON DR
Second Line	:	SUITE I
City	:	RIDGELAND
State	:	MS
Zip	:	39157-5161
Country	:	US
Telephone Number	:	601-607-7195
Fax Number	:	601-607-7196

Provider Business Practice Location Address
First Line	:	2975 GARDEN ST
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33917-1883
Country	:	US
Telephone Number	:	239-995-5833
Fax Number	:	239-995-4856

Authorized Official
Title or Position	:	DIRECTOR OF REIMBURSEMENT
Name	:	MRS. JAMIE LATTURE COLLIER
Credential	:
Telephone Number	:	601-607-7195

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	08/22/2020

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