Provider Demographics
NPI:1306183066
Name:DELUCA, DAVID DAMIAN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DAMIAN
Last Name:DELUCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95609-1595
Mailing Address - Country:US
Mailing Address - Phone:916-501-5001
Mailing Address - Fax:916-570-3274
Practice Address - Street 1:5216 EL CAMINO AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-5015
Practice Address - Country:US
Practice Address - Phone:916-501-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347003032310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility