Healthcare Provider Details

I. General information

NPI: 1972805919
Provider Name (Legal Business Name): DELTA CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 RICHLAND TER
MOUNDS IL
62964-1233
US

IV. Provider business mailing address

130 RICHLAND TER
MOUNDS IL
62964-1233
US

V. Phone/Fax

Practice location:
  • Phone: 618-734-2665
  • Fax: 618-734-1999
Mailing address:
  • Phone: 618-734-2665
  • Fax: 618-734-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number094500030
License Number StateIL

VIII. Authorized Official

Name: MRS. LISA TOLBERT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-734-2665