Provider Demographics
NPI:1689315707
Name:MBK RESIDENTIAL SERVICES LLC
Entity Type:Organization
Organization Name:MBK RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALHOUN-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-414-7251
Mailing Address - Street 1:6740 THIRLANE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2908
Mailing Address - Country:US
Mailing Address - Phone:864-414-7251
Mailing Address - Fax:
Practice Address - Street 1:6740 THIRLANE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2908
Practice Address - Country:US
Practice Address - Phone:864-414-7251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities