MEDICARE: OPEN MINDED DEVELOPMENTAL SERVICES, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1215742713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN MINDED DEVELOPMENTAL SERVICES, INC

Provider Business Mailing Address
First Line	:	2803 SUNSET AVE
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-3644
Country	:	US
Telephone Number	:	252-446-1411
Fax Number	:	252-446-3351

Provider Business Practice Location Address
First Line	:	2803 SUNSET AVE
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-3644
Country	:	US
Telephone Number	:	252-446-1411
Fax Number	:	252-446-3351

Authorized Official
Title or Position	:	CREDENTIALING SPECIALISTS
Name	:	KIMBERLY DAVIS
Credential	:
Telephone Number	:	912-373-4385

Provider Enumeration Date	:	02/11/2025
Last Update Date	:	02/11/2025

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