1609895762 NPI number — STATE OF DE

Table of content: (NPI 1609895762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609895762 NPI number — STATE OF DE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF DE
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:
NC COMMUNITY MENTAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1609895762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 SW FRONT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19963-1948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-422-1422
Provider Business Mailing Address Fax Number:
302-422-1375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 N WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19801-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-577-6490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOTULA
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL DIRECTOR/DIRECTOR OF CLINCI
Authorized Official Telephone Number:
302-576-6093

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 609724 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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