Provider Demographics
NPI:1164276622
Name:BERRY, MERCELL
Entity Type:Individual
Prefix:
First Name:MERCELL
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 WESTWOOD SHOPPING CENTER
Mailing Address - Street 2:PMB1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314
Mailing Address - Country:US
Mailing Address - Phone:919-841-2905
Mailing Address - Fax:
Practice Address - Street 1:439 WESTWOOD SHOPPING CENTER
Practice Address - Street 2:PMB1
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314
Practice Address - Country:US
Practice Address - Phone:919-841-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)