1093860264 NPI number — STATE OF DELAWARE-DDDS AS.LIV

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093860264 NPI number — STATE OF DELAWARE-DDDS AS.LIV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF DELAWARE-DDDS AS.LIV
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:
DDDS ASSISTED LIVING
Provider Other Organization Name Type Code:
5
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:
1093860264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1056 S GOVERNORS AVE
Provider Second Line Business Mailing Address:
WOODBROOK PROFESSIONAL CTR, STE. 101
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19904-6920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-744-9600
Provider Business Mailing Address Fax Number:
302-744-7631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26351 PATRIOTS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19947-2575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-933-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
SOCIAL SERVICE CHIEF ADMINISTRATOR
Authorized Official Telephone Number:
302-741-9349

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  1481 , 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: 001150374 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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