Healthcare Provider Details

I. General information

NPI: 1649642075
Provider Name (Legal Business Name): DELTA VALLEY DEVELOPMENT CORP #2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 JACKSON STREET
BELZONI MS
39038-0117
US

IV. Provider business mailing address

PO BOX 427
ITTA BENA MS
38941-0427
US

V. Phone/Fax

Practice location:
  • Phone: 662-704-5037
  • Fax: 662-704-5008
Mailing address:
  • Phone: 662-704-5037
  • Fax: 662-704-5008

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: MRS. VIOLA MCCASKILL
Title or Position: OWNER
Credential:
Phone: 66627045037