Provider Demographics
NPI:1437523511
Name:DELTA PEDIATRIC CARE
Entity Type:Organization
Organization Name:DELTA PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:318-512-9218
Mailing Address - Street 1:PO BOX 2994
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-2994
Mailing Address - Country:US
Mailing Address - Phone:662-580-5074
Mailing Address - Fax:662-580-5074
Practice Address - Street 1:526 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-5401
Practice Address - Country:US
Practice Address - Phone:662-580-5074
Practice Address - Fax:662-580-5074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric