Provider Demographics
NPI:1194033886
Name:MERCYLAND SERVICES LLC
Entity Type:Organization
Organization Name:MERCYLAND SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:FUNMI
Authorized Official - Middle Name:FEYIKEMI
Authorized Official - Last Name:FASOLE
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:770-815-9471
Mailing Address - Street 1:4760 AUSTELL RD ,SUITE 6
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-2007
Mailing Address - Country:US
Mailing Address - Phone:770-574-4613
Mailing Address - Fax:770-726-9783
Practice Address - Street 1:4760 AUSTELL RD STE 6
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-2007
Practice Address - Country:US
Practice Address - Phone:770-574-4613
Practice Address - Fax:770-726-9783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-0564251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health