Provider Demographics
NPI:1326193186
Name:OPEN DOOR MGMT AGENCY OF JACKSONVILLE
Entity Type:Organization
Organization Name:OPEN DOOR MGMT AGENCY OF JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-577-4175
Mailing Address - Street 1:896 LYNCHBURG DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6010
Mailing Address - Country:US
Mailing Address - Phone:910-577-4175
Mailing Address - Fax:910-455-7068
Practice Address - Street 1:1675 HALLTOWN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-4565
Practice Address - Country:US
Practice Address - Phone:910-346-7513
Practice Address - Fax:910-346-9431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid