Provider Demographics
NPI:1619579208
Name:DELTA LIFESTYLE SOLUTIONS
Entity Type:Organization
Organization Name:DELTA LIFESTYLE SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:304-623-6300
Mailing Address - Street 1:PO BOX 4246
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26302-4246
Mailing Address - Country:US
Mailing Address - Phone:304-623-6300
Mailing Address - Fax:
Practice Address - Street 1:109 TOLLEY DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1669
Practice Address - Country:US
Practice Address - Phone:304-623-6300
Practice Address - Fax:304-623-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1639326747Medicaid