Healthcare Provider Details

I. General information

NPI: 1619543881
Provider Name (Legal Business Name): DLC DELTA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 S E ST
PENSACOLA FL
32502-4569
US

IV. Provider business mailing address

259 S E ST
PENSACOLA FL
32502-4569
US

V. Phone/Fax

Practice location:
  • Phone: 734-389-5832
  • Fax:
Mailing address:
  • Phone: 734-389-5832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GERALD MASTAW
Title or Position: INTERIM CEO
Credential: MD
Phone: 734-389-5832