Provider Demographics
NPI:1407934458
Name:DELTA HEALTH CARE AND MANAGMENT SERVICES CORP.
Entity Type:Organization
Organization Name:DELTA HEALTH CARE AND MANAGMENT SERVICES CORP.
Other - Org Name:DELTA HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-751-3920
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0550
Mailing Address - Country:US
Mailing Address - Phone:209-751-3920
Mailing Address - Fax:209-751-3919
Practice Address - Street 1:1425 S CENTER ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-2016
Practice Address - Country:US
Practice Address - Phone:209-751-3920
Practice Address - Fax:209-751-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000682261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP11503GOtherEAPC
CACMM70825FMedicaid
CACMM70920FMedicaid
CACMM70817FMedicaid
CAZZR11503GMedicaid