MEDICARE: MECKLENBURG OPEN DOOR, 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	261QM0850X	Adult Mental Health Clinic/Center	MHL-060-248	NC

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	:	1750414132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLENBURG OPEN DOOR, INC.

Provider Business Mailing Address
First Line	:	1515 MOCKINGBIRD LN
Second Line	:	SUITE 1015
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3236
Country	:	US
Telephone Number	:	704-525-3255
Fax Number	:	704-525-0949

Provider Business Practice Location Address
First Line	:	3711 CARMEL FOREST DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-8117
Country	:	US
Telephone Number	:	704-542-8727
Fax Number	:	704-542-9198

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. EDWARD G PAYTON
Credential	:
Telephone Number	:	704-525-3255

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	08/22/2020

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