1245342021 NPI number — MERCED MANOR, INC.

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 1245342021 NPI number — MERCED MANOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCED MANOR, INC.
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:
MERCED BEHAVIORAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1245342021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
632 E YOSEMITE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADERA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93638-3343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-673-5149
Provider Business Mailing Address Fax Number:
559-673-7249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 B ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340-6345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-723-8814
Provider Business Practice Location Address Fax Number:
209-384-3747
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
ARDEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
559-673-5149

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZR18469G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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