Healthcare Provider Details

I. General information

NPI: 1740427780
Provider Name (Legal Business Name): MERCLAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 CRESTWOOD STA STE A
CRESTWOOD KY
40014-7418
US

IV. Provider business mailing address

6200 CRESTWOOD STA STE A
CRESTWOOD KY
40014-7418
US

V. Phone/Fax

Practice location:
  • Phone: 501-242-2909
  • Fax:
Mailing address:
  • Phone: 501-242-2909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number251000000
License Number StateKY

VIII. Authorized Official

Name: JEFFREY MERCER
Title or Position: DIRECTOR
Credential:
Phone: 502-241-2909