Provider Demographics
NPI:1558167445
Name:MERCYGATE HEALTH SERVICES LLC
Entity type:Organization
Organization Name:MERCYGATE HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KEO
Authorized Official - Middle Name:
Authorized Official - Last Name:SENGSAVANG
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:612-234-1823
Mailing Address - Street 1:2647 BLOOMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1137
Mailing Address - Country:US
Mailing Address - Phone:612-282-2053
Mailing Address - Fax:
Practice Address - Street 1:2647 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1137
Practice Address - Country:US
Practice Address - Phone:612-282-2053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health