MEDICARE: MITCHELL4D, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1861629487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MITCHELL4D, LLC

Provider Business Mailing Address
First Line	:	8105 OLD CONCORD RD
Second Line	:	502
City	:	NEWELL
State	:	NC
Zip	:	28126-9999
Country	:	US
Telephone Number	:	704-453-1993
Fax Number	:	704-248-8392

Provider Business Practice Location Address
First Line	:	7736 WATERFORD LAKES DR
Second Line	:	SUITE 1423
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-7485
Country	:	US
Telephone Number	:	704-453-1993
Fax Number	:	704-248-8392

Authorized Official
Title or Position	:	MEMBER
Name	:	MS. YOLONDA MITCHELL
Credential	:
Telephone Number	:	704-453-1993

Provider Enumeration Date	:	06/22/2009
Last Update Date	:	06/22/2009

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