Provider Demographics
NPI:1003012758
Name:G & D RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:G & D RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEOVON
Authorized Official - Middle Name:KENANE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-254-6770
Mailing Address - Street 1:620 GUILFORD COLLEGE RD STE G
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2027
Mailing Address - Country:US
Mailing Address - Phone:336-254-6770
Mailing Address - Fax:336-292-1589
Practice Address - Street 1:620 GUILFORD COLLEGE RD STE G
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-2027
Practice Address - Country:US
Practice Address - Phone:336-254-6770
Practice Address - Fax:336-292-1589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-764320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300792BMedicaid