Provider Demographics
NPI:1801331699
Name:MISSION OF MERCY, INC. (MOMS, INC.)
Entity type:Organization
Organization Name:MISSION OF MERCY, INC. (MOMS, INC.)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT, CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, ALC
Authorized Official - Phone:256-617-4263
Mailing Address - Street 1:204 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-5532
Mailing Address - Country:US
Mailing Address - Phone:256-617-4263
Mailing Address - Fax:
Practice Address - Street 1:414 E TUSCALOOSA ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-4726
Practice Address - Country:US
Practice Address - Phone:256-617-4263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5095324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility