NPIMap

Organization Active NPI

Autism Services of Mecklenburg County, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Charlotte, NC
National Provider Identifier
1043561764
Registry record updated Sep 20, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
MHL-060-231 Issued in NC
Legal business name
AUTISM SERVICES OF MECKLENBURG COUNTY, INC.
Practice address
1123 Ravendale Dr
Charlotte, NC 28216-1526
Phone
(704) 399-3538
NPI assigned
Sep 20, 2012
Last updated
Sep 20, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 20, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jack Marcellous Phillips Jr., MA
Title
Executive Director/Ceo
Phone
(704) 392-9220

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X MHL-060-231 NC Primary

Addresses

Primary practice location

1123 Ravendale Dr
Charlotte, NC 28216-1526

Mailing address

2211 Executive St
Suite a
Charlotte, NC 28208-3661
Phone (704) 392-9220

Other identifiers 1

IdentifierTypeStateIssuer
340609AMedicaidNC

National Provider Directory

National Provider Directory
Tax ID family
Autism Services of Mecklenburg County Inc9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1348099200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1348099200000",
    "number": "1043561764",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2211 EXECUTIVE ST",
            "address_2": "SUITE A",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282083661",
            "telephone_number": "704-392-9220",
            "fax_number": "704-392-9221"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1123 RAVENDALE DR",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282161526",
            "telephone_number": "704-399-3538"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AUTISM SERVICES OF MECKLENBURG COUNTY, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-20",
        "last_updated": "2012-09-20",
        "status": "A",
        "authorized_official_last_name": "PHILLIPS",
        "authorized_official_first_name": "JACK",
        "authorized_official_middle_name": "MARCELLOUS",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR/CEO",
        "authorized_official_telephone_number": "704-392-9220",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "MA"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "NC",
            "license": "MHL-060-231",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "340609A",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Charlotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.