Provider Demographics
NPI:1386093144
Name:MERCED CARE HOME LLC
Entity type:Organization
Organization Name:MERCED CARE HOME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELBA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-516-4399
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:813-516-4399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-11
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015674300Medicaid