Provider Demographics
NPI:1821399890
Name:M&D RESIDENTIAL SERVICES, INC
Entity Type:Organization
Organization Name:M&D RESIDENTIAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENSIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-807-1250
Mailing Address - Street 1:2556 SW MONTERREY LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2956
Mailing Address - Country:US
Mailing Address - Phone:772-807-1205
Mailing Address - Fax:
Practice Address - Street 1:2556 SW MONTERREY LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2956
Practice Address - Country:US
Practice Address - Phone:772-807-1205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL151446320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686560796Medicaid