Provider Demographics
NPI:1124418595
Name:MERCYS SUPPORTIVE LIVING
Entity Type:Organization
Organization Name:MERCYS SUPPORTIVE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:BRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-443-6811
Mailing Address - Street 1:932 COBBLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-7868
Mailing Address - Country:US
Mailing Address - Phone:252-443-6811
Mailing Address - Fax:252-443-6811
Practice Address - Street 1:932 COBBLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-7868
Practice Address - Country:US
Practice Address - Phone:252-443-6811
Practice Address - Fax:252-443-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL064-027311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home