Basic Information
| Provider Information | |||||||||
| NPI: | 1225279490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MECKLENBURG OPEN DOOR/CHARLOTTETOWN CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 MOCKINGBIRD LANE | ||||||||
| Address2: | SUITE 1015 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045253255 | ||||||||
| FaxNumber: | 7045250949 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 E INDEPENDENCE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282057261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045253255 | ||||||||
| FaxNumber: | 7045250949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | PAYTON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7045253255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.