Provider Demographics
NPI:1821294570
Name:G & D RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:G & D RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEOVON
Authorized Official - Middle Name:KENANE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:336-254-6770
Mailing Address - Street 1:800 SPRUILL CT
Mailing Address - Street 2:SUITE E
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-3042
Mailing Address - Country:US
Mailing Address - Phone:336-254-6770
Mailing Address - Fax:336-272-8083
Practice Address - Street 1:1208 SLOAN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3442
Practice Address - Country:US
Practice Address - Phone:336-254-6770
Practice Address - Fax:336-272-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-764320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300792HMedicaid