1053373308 NPI number — VICKI M MERRICK DC PA

Table of content: (NPI 1053373308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053373308 NPI number — VICKI M MERRICK DC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICKI M MERRICK DC PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053373308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100246
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32910-0246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-952-7004
Provider Business Mailing Address Fax Number:
321-952-1004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2060 PALM BAY RD NE
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
PALM BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32905-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-952-7004
Provider Business Practice Location Address Fax Number:
321-952-1004
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MERRICK
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-952-7004

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH5958 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 267605 . This is a "STAYWELL HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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