MEDICARE: AUTISM SERVICES OF MECKLENBURG COUNTY, 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	315P00000X	Intellectual Disabilities Intermediate Care Facility	MHL-060-514	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	:	1063764702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTISM SERVICES OF MECKLENBURG COUNTY, INC.

Provider Business Mailing Address
First Line	:	2211 EXECUTIVE ST
Second Line	:	SUITE A
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-3661
Country	:	US
Telephone Number	:	704-392-9220
Fax Number	:	704-392-9221

Provider Business Practice Location Address
First Line	:	5917 ROWAN WAY
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214
Country	:	US
Telephone Number	:	704-391-5559
Fax Number	:	704-391-5560

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/CEO
Name	:	MR. JACK MARCELLOUS PHILLIPS JR.
Credential	:	MA
Telephone Number	:	704-392-9220

Provider Enumeration Date	:	10/04/2012
Last Update Date	:	01/10/2013

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