Healthcare Provider Details

I. General information

NPI: 1245287721
Provider Name (Legal Business Name): DETA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 HOLEMAN AVE
SOUTH CHICAGO HEIGHTS IL
60411-5515
US

IV. Provider business mailing address

3259 HOLEMAN AVE
SOUTH CHICAGO HEIGHTS IL
60411-5515
US

V. Phone/Fax

Practice location:
  • Phone: 708-756-7440
  • Fax: 708-756-7680
Mailing address:
  • Phone: 708-756-7440
  • Fax: 708-756-7680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. ERMELINDA P. DJONDO
Title or Position: VICE-PRESIDENT
Credential: COLLEGE GRADUATE
Phone: 708-756-7440