Basic Information
Provider Information | |||||||||
NPI: | 1467782102 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DELTA CARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4705 N SONORA AVE STE 113 | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937223965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5592767558 | ||||||||
FaxNumber: | 5592767568 | ||||||||
Practice Location | |||||||||
Address1: | 4705 N SONORA AVE | ||||||||
Address2: | SUITE 113 | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937223966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5592767558 | ||||||||
FaxNumber: | 5592767568 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2009 | ||||||||
LastUpdateDate: | 12/31/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ENUNWA | ||||||||
AuthorizedOfficialFirstName: | RITA | ||||||||
AuthorizedOfficialMiddleName: | OBIAJULUM | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5592767558 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSN, FNP-C | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 100082AN | CA | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.