Provider Demographics
NPI:1174825020
Name:DELTA CENTER, INC
Entity Type:Organization
Organization Name:DELTA CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-734-2665
Mailing Address - Street 1:1400 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:IL
Mailing Address - Zip Code:62914-1978
Mailing Address - Country:US
Mailing Address - Phone:618-734-2665
Mailing Address - Fax:618-734-1999
Practice Address - Street 1:2107 PINE ST
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-1613
Practice Address - Country:US
Practice Address - Phone:618-734-2665
Practice Address - Fax:618-734-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04045261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)