Healthcare Provider Details

I. General information

NPI: 1629101225
Provider Name (Legal Business Name): MECKLENBURG OPEN DOOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 MCALWAY RD
CHARLOTTE NC
28211-1414
US

IV. Provider business mailing address

1515 MOCKINGBIRD LN SUITE #1015
CHARLOTTE NC
28209-3236
US

V. Phone/Fax

Practice location:
  • Phone: 704-364-0432
  • Fax:
Mailing address:
  • Phone: 704-525-3255
  • Fax: 704-525-0949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL-060-996
License Number StateNC

VIII. Authorized Official

Name: MR. EDWARD G PAYTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 704-525-3255