=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851392500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA SKILLED NURSING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2005
-----------------------------------------------------
Last Update Date | 11/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1334 S HAM LN
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95242-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-334-3825
-----------------------------------------------------
Fax | 209-368-7714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1334 S HAM LN
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95242-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-334-3825
-----------------------------------------------------
Fax | 209-368-7714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TERRY BANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-897-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 030000138
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------