MEDICARE: KMB RESIDENTIAL LLC

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1841076544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMB RESIDENTIAL LLC

Provider Business Mailing Address
First Line	:	2500 BELMONT STAKES DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-8128
Country	:	US
Telephone Number	:	757-289-6447
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 BELMONT STAKES DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-8128
Country	:	US
Telephone Number	:	757-289-6447
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	KALYN M BLACKSHEAR
Credential	:
Telephone Number	:	577-289-6447

Provider Enumeration Date	:	09/07/2023
Last Update Date	:	09/07/2023

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