Healthcare Provider Details

I. General information

NPI: 1699591388
Provider Name (Legal Business Name): MERCURY NEWCO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 COLUMBIA RD
BOSTON MA
02121-3409
US

IV. Provider business mailing address

584 MARKET ST STE 17462
SAN FRANCISCO CA
94104
US

V. Phone/Fax

Practice location:
  • Phone: 443-498-3972
  • Fax:
Mailing address:
  • Phone: 443-498-3972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL DAI
Title or Position: DIRECTOR, BUSINESS OPERATIONS
Credential:
Phone: 443-498-3972