1356336622 NPI number — CHANCELLOR CARE CENTER OF DELMAR

Table of content: (NPI 1356336622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356336622 NPI number — CHANCELLOR CARE CENTER OF DELMAR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANCELLOR CARE CENTER OF DELMAR
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:
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:
1356336622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12904 BUCKEYE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DARNESTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20878-3532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-846-3077
Provider Business Mailing Address Fax Number:
302-846-3148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 DELAWARE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELMAR
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19940-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-846-3077
Provider Business Practice Location Address Fax Number:
302-846-3148
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLANGELO
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
302-846-3077

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1028 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000429612 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000430011 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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