Provider Demographics
NPI:1194273318
Name:MERCED, MELBA
Entity type:Individual
Prefix:
First Name:MELBA
Middle Name:
Last Name:MERCED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273372
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-3372
Mailing Address - Country:US
Mailing Address - Phone:813-516-4399
Mailing Address - Fax:
Practice Address - Street 1:4616 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6634
Practice Address - Country:US
Practice Address - Phone:403-516-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015674300Medicaid