MEDICARE: MERCED CARE HOME LLC

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	251C00000X	Developmentally Disabled Services Day Training Agency		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386093144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCED CARE HOME LLC

Provider Business Mailing Address
First Line	:	PO BOX 273372
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33688-3372
Country	:	US
Telephone Number	:	813-516-4399
Fax Number	:

Provider Business Practice Location Address
First Line	:	4616 N LINCOLN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6634
Country	:	US
Telephone Number	:	813-516-4399
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MELBA MERCED
Credential	:
Telephone Number	:	813-516-4399

Provider Enumeration Date	:	06/11/2016
Last Update Date	:	06/11/2016

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