Provider Demographics
NPI:1619543881
Name:DLC DELTA, INC.
Entity Type:Organization
Organization Name:DLC DELTA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-389-5832
Mailing Address - Street 1:259 S E ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-4569
Mailing Address - Country:US
Mailing Address - Phone:734-389-5832
Mailing Address - Fax:
Practice Address - Street 1:259 S E ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4569
Practice Address - Country:US
Practice Address - Phone:734-389-5832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty