MEDICARE: MULTI-DIMENSIONAL SERVICES & SUPPORTS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205132578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULTI-DIMENSIONAL SERVICES & SUPPORTS, INC.

Provider Business Mailing Address
First Line	:	2835 LORIMIER TER
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4146
Country	:	US
Telephone Number	:	904-398-8235
Fax Number	:	904-398-8235

Provider Business Practice Location Address
First Line	:	2835 LORIMIER TER
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4146
Country	:	US
Telephone Number	:	904-398-8235
Fax Number	:	904-398-8235

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MS. MARTHA FORNOF
Credential	:
Telephone Number	:	904-398-8235

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	02/04/2011

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