Provider Demographics
NPI:1609895762
Name:STATE OF DE
Entity Type:Organization
Organization Name:STATE OF DE
Other - Org Name:NC COMMUNITY MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR/DIRECTOR OF CLINCI
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOTULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-576-6093
Mailing Address - Street 1:10 SW FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1948
Mailing Address - Country:US
Mailing Address - Phone:302-422-1422
Mailing Address - Fax:302-422-1375
Practice Address - Street 1:809 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1509
Practice Address - Country:US
Practice Address - Phone:302-577-6490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE609724Medicaid
DE629454Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER