1093040388 NPI number — MERCY'S QUALITY HOME CARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093040388 NPI number — MERCY'S QUALITY HOME CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY'S QUALITY HOME CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093040388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 N BERRY ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-3411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-608-7151
Provider Business Mailing Address Fax Number:
678-289-9256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 N BERRY ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-1093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-608-7151
Provider Business Practice Location Address Fax Number:
678-289-9256
Provider Enumeration Date:
10/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EKPOUDOM
Authorized Official First Name:
MERCY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
678-608-7151

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003137788A . This is a "MEDICAID PROVDER #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003137789 . This is a "MEDICAID PROVIDER #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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