Provider Demographics
NPI:1710122114
Name:MELROSE CENTER
Entity Type:Organization
Organization Name:MELROSE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-536-2253
Mailing Address - Street 1:421 MAIDEN LN
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5055
Mailing Address - Country:US
Mailing Address - Phone:910-536-2256
Mailing Address - Fax:
Practice Address - Street 1:421 MAIDEN LN STE 207
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5055
Practice Address - Country:US
Practice Address - Phone:910-536-2253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-14
Last Update Date:2008-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid