Provider Demographics
NPI:1366030561
Name:HIS MERCY ASSISTED LLC
Entity Type:Organization
Organization Name:HIS MERCY ASSISTED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYO
Authorized Official - Middle Name:
Authorized Official - Last Name:AGORO
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:623-600-8926
Mailing Address - Street 1:12362 W JOBLANCA RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-3130
Mailing Address - Country:US
Mailing Address - Phone:623-600-8926
Mailing Address - Fax:
Practice Address - Street 1:12362 W JOBLANCA RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-3130
Practice Address - Country:US
Practice Address - Phone:623-600-8926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6411OtherSTATE