Basic Information
| Provider Information | |||||||||
| NPI: | 1326474008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MELANGE HEALTH SOLUTIONS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29234 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282299234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045678690 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1818 WEST FIFTH AVENUE | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046714123 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7045678690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | MHL-036-295 | NC | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | MHL -036-295 | 01 | NC | DHHS LICENSE | OTHER |