MEDICARE: CAROLINA OUTPATIENT DETOX, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1710701149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA OUTPATIENT DETOX, LLC

Provider Business Mailing Address
First Line	:	1117 E MOREHEAD ST STE 100
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2870
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 E MOREHEAD ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2895
Country	:	US
Telephone Number	:	859-304-4047
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SHANNON ERB
Credential	:
Telephone Number	:	859-304-4047

Provider Enumeration Date	:	11/12/2024
Last Update Date	:	02/17/2025

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