Provider Demographics
NPI:1518101609
Name:RESIDENTIAL SERVICES OF VOLUSIA COUNTY
Entity Type:Organization
Organization Name:RESIDENTIAL SERVICES OF VOLUSIA COUNTY
Other - Org Name:RSVC -DIXIE LODGE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALKER
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:M ED
Authorized Official - Phone:386-734-4830
Mailing Address - Street 1:647 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-5810
Mailing Address - Country:US
Mailing Address - Phone:386-734-4830
Mailing Address - Fax:386-734-4536
Practice Address - Street 1:647 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5810
Practice Address - Country:US
Practice Address - Phone:386-734-4830
Practice Address - Fax:386-734-4536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10773104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142116600Medicaid