1962699751 NPI number — MERRILL COMMUNITY SERV INC

Table of content: (NPI 1962699751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962699751 NPI number — MERRILL COMMUNITY SERV INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRILL COMMUNITY SERV 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:
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:
1962699751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9161 SIERRA AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92335-4729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-823-0609
Provider Business Mailing Address Fax Number:
909-823-4187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9161 SIERRA AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-823-0609
Provider Business Practice Location Address Fax Number:
909-823-4187
Provider Enumeration Date:
09/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BATISTE
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
DEAVON
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
909-823-0609

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  360016AN , 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: 363648 . This is a "MED I CAL" identifier . This identifiers is of the category "OTHER".




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