Provider Demographics
NPI:1447754478
Name:M&M SUPPORTIVE LIVING SERVICES
Entity Type:Organization
Organization Name:M&M SUPPORTIVE LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:POLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-616-8146
Mailing Address - Street 1:2514 MAYAPPLE RD E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-4268
Mailing Address - Country:US
Mailing Address - Phone:904-616-8146
Mailing Address - Fax:
Practice Address - Street 1:2514 MAYAPPLE RD E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-4268
Practice Address - Country:US
Practice Address - Phone:904-616-8146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities