Organization
AUTISM SERVICES OF MECKLENBURG COUNTY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JACK MARCELLOUS PHILLIPS JR. MA (EXECUTIVE DIRECTOR/CEO)
(704) 392-9220
Entity
Organization
Contact information
Practice address
4319 MANTLE CT, CHARLOTTE, NC 28205-7243
(704) 567-8082
Mailing address
2211 EXECUTIVE ST, SUITE A, CHARLOTTE, NC 28208-3661
(704) 392-9220
(704) 392-9221
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
MHL-060-167
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
340602B
—
NC
Enumeration date
09/20/2012
Last updated
09/20/2012
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