Provider Demographics
NPI:1790344901
Name:FIRST STATE RESIDENTIAL LIVING LLC
Entity Type:Organization
Organization Name:FIRST STATE RESIDENTIAL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANNINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:302-322-2743
Mailing Address - Street 1:92 READS WAY UNIT 108
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-1631
Mailing Address - Country:US
Mailing Address - Phone:302-322-2743
Mailing Address - Fax:302-450-1368
Practice Address - Street 1:92 READS WAY UNIT 108
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-1631
Practice Address - Country:US
Practice Address - Phone:302-322-2743
Practice Address - Fax:302-450-1368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty