Healthcare Provider Details

I. General information

NPI: 1750577904
Provider Name (Legal Business Name): CMC-NORTHEAST PSYCHIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 COPPERFIELD BLVD NE
CONCORD NC
28025-2402
US

IV. Provider business mailing address

380 COPPERFIELD BLVD NE
CONCORD NC
28025-2402
US

V. Phone/Fax

Practice location:
  • Phone: 704-262-1822
  • Fax: 704-262-1850
Mailing address:
  • Phone: 704-262-1822
  • Fax: 704-262-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4329
License Number StateNC

VIII. Authorized Official

Name: DR. JONATHAN MCKENZIE
Title or Position: CHIEF OF PSYCHIATRY
Credential: M.D.
Phone: 704-262-1800