Provider Demographics
NPI:1790819621
Name:MECKLENBURG OPEN DOOR, INC.
Entity Type:Organization
Organization Name:MECKLENBURG OPEN DOOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:PAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-525-3255
Mailing Address - Street 1:1515 MOCKINGBIRD LN
Mailing Address - Street 2:SUITE 1015
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3236
Mailing Address - Country:US
Mailing Address - Phone:704-525-3255
Mailing Address - Fax:704-525-0949
Practice Address - Street 1:245 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-1212
Practice Address - Country:US
Practice Address - Phone:704-375-0775
Practice Address - Fax:704-375-7902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-048261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802706Medicaid