Provider Demographics
NPI:1275867830
Name:MDR COMMUNITY LIVING
Entity Type:Organization
Organization Name:MDR COMMUNITY LIVING
Other - Org Name:MDR COMMUNITY LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:LAMONTE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-455-6303
Mailing Address - Street 1:6000 HOLLISTER ST APT 2711
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6878
Mailing Address - Country:US
Mailing Address - Phone:832-455-6303
Mailing Address - Fax:
Practice Address - Street 1:6000 HOLLISTER ST APT 2711
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-6878
Practice Address - Country:US
Practice Address - Phone:832-455-6303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities