Provider Demographics
NPI:1831147677
Name:DESOTO COMMUNITY CARE CENTER LLC
Entity type:Organization
Organization Name:DESOTO COMMUNITY CARE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:3068 NAIL RD W
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-3002
Mailing Address - Country:US
Mailing Address - Phone:662-280-1219
Mailing Address - Fax:662-280-4668
Practice Address - Street 1:3068 NAIL RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-3002
Practice Address - Country:US
Practice Address - Phone:662-280-1219
Practice Address - Fax:662-280-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS943314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230171Medicaid
MS000080379OtherBLUE CROSS BLUE SHIELD MS
MS00230171Medicaid