Provider Demographics
NPI:1558417683
Name:STATE OF DELAWARE
Entity Type:Organization
Organization Name:STATE OF DELAWARE
Other - Org Name:GENERAL PRACTICE STOCKLEY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OF ADMINISTRATION
Authorized Official - Prefix:MS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-744-9600
Mailing Address - Street 1:26351 PATRIOTS WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-2575
Mailing Address - Country:US
Mailing Address - Phone:302-933-3000
Mailing Address - Fax:302-934-1376
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:302-934-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1047315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE166940Medicare ID - Type Unspecified