Basic Information
| Provider Information | |||||||||
| NPI: | 1700101169 | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2216 SOUTH MIAMI BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277034915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045678690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
| AuthorizedOfficialTelephone: | 7045678690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8302355 | 05 | NC | MEDICAID |