Healthcare Provider Details

I. General information

NPI: 1275739062
Provider Name (Legal Business Name): DELTA FAMILY HEALTH AND FITNESS CENTER FOR CHILDREN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 E SAINT LOUIS ST
HAMBURG AR
71646-2766
US

IV. Provider business mailing address

100 W POLK ST
HAMBURG AR
71646-3179
US

V. Phone/Fax

Practice location:
  • Phone: 870-853-4224
  • Fax: 870-853-9909
Mailing address:
  • Phone: 870-853-4224
  • Fax: 870-853-9909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number20101
License Number StateAR

VIII. Authorized Official

Name: MR. PATRICK LEONARD FIELDS
Title or Position: ADMINISTRATOR
Credential:
Phone: 870-853-4224