Provider Demographics
NPI:1093860264
Name:STATE OF DELAWARE-DDDS AS.LIV
Entity Type:Organization
Organization Name:STATE OF DELAWARE-DDDS AS.LIV
Other - Org Name:DDDS ASSISTED LIVING
Other - Org Type:Other Name
Authorized Official - Title/Position:SOCIAL SERVICE CHIEF ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:F
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-741-9349
Mailing Address - Street 1:1056 S GOVERNORS AVE
Mailing Address - Street 2:WOODBROOK PROFESSIONAL CTR, STE. 101
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-6920
Mailing Address - Country:US
Mailing Address - Phone:302-744-9600
Mailing Address - Fax:302-744-7631
Practice Address - Street 1:26351 PATRIOTS WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2575
Practice Address - Country:US
Practice Address - Phone:302-933-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1481310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE001150374Medicaid