Healthcare Provider Details

I. General information

NPI: 1790004786
Provider Name (Legal Business Name): LA RED HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 05/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 S BRADFORD ST
DOVER DE
19904-4141
US

IV. Provider business mailing address

505 W MARKET ST
GEORGETOWN DE
19947-2344
US

V. Phone/Fax

Practice location:
  • Phone: 302-855-1233
  • Fax: 302-855-1020
Mailing address:
  • Phone: 302-855-1233
  • Fax: 302-855-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN OLSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 302-855-2020