MEDICARE: MERRILL COMMUNITY SERV INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	360016AN	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	363648	OTHER		MED I CAL

General Provider Information

NPI Number	:	1962699751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERRILL COMMUNITY SERV INC

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

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

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. WARREN DEAVON BATISTE
Credential	:
Telephone Number	:	909-823-0609

Provider Enumeration Date	:	09/26/2007
Last Update Date	:	03/03/2009

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