Provider Demographics
NPI:1427869866
Name:VINE RESIDENTIAL SERVICES
Entity type:Organization
Organization Name:VINE RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-473-9773
Mailing Address - Street 1:703 N CAREY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-2412
Mailing Address - Country:US
Mailing Address - Phone:443-473-9773
Mailing Address - Fax:
Practice Address - Street 1:707 NORRIS LN
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-2140
Practice Address - Country:US
Practice Address - Phone:443-473-9773
Practice Address - Fax:443-961-8169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities