Provider Demographics
NPI:1902404627
Name:MERCER, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MERCER
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 1:703 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-2915
Mailing Address - Country:US
Mailing Address - Phone:540-671-9238
Mailing Address - Fax:
Practice Address - Street 1:703 W 14TH ST
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-2915
Practice Address - Country:US
Practice Address - Phone:540-671-9238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT66738085172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver