Provider Demographics
NPI:1417146531
Name:M&S SUPERVISED LIVING LLC
Entity Type:Organization
Organization Name:M&S SUPERVISED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIBILLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-656-7767
Mailing Address - Street 1:7312 FRIENDSHIP CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7311A FRIENDSHIP CHURCH RD
Practice Address - Street 2:
Practice Address - City:BROWNS SUMMIT
Practice Address - State:NC
Practice Address - Zip Code:27214-9728
Practice Address - Country:US
Practice Address - Phone:336-656-7809
Practice Address - Fax:336-295-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL041613320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities