Provider Demographics
NPI:1124168141
Name:MARTIN COUNTY RESIDENTIAL SERVICES INC.
Entity type:Organization
Organization Name:MARTIN COUNTY RESIDENTIAL SERVICES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-792-8251
Mailing Address - Street 1:PO BOX 1042
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-1042
Mailing Address - Country:US
Mailing Address - Phone:252-792-8251
Mailing Address - Fax:252-792-5283
Practice Address - Street 1:6003 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892
Practice Address - Country:US
Practice Address - Phone:252-792-8251
Practice Address - Fax:252-792-5283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL058002171M00000X, 373H00000X
NCMHL058004320900000X, 376J00000X
NCMHLO58003376J00000X
NCMHL058003320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty