=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558167445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCYGATE HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2647 BLOOMINGTON AVE
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55407-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-282-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2647 BLOOMINGTON AVE
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55407-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-282-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING AGENT
-----------------------------------------------------
Name | KEO SENGSAVANG
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 612-234-1823
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------