Healthcare Provider Details

I. General information

NPI: 1780130930
Provider Name (Legal Business Name): DELTA SOUTH ADULT CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 COLONEL GEORGE E DAY PARKWAY
SIKESTON MO
63801
US

IV. Provider business mailing address

1515 E MALONE AVE
SIKESTON MO
63801-3413
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-0466
  • Fax: 573-471-4918
Mailing address:
  • Phone: 573-471-0466
  • Fax: 573-471-4918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRY COLE
Title or Position: OWNER
Credential:
Phone: 573-471-0466