Provider Demographics
NPI:1699843003
Name:STATE OF DELAWARE
Entity Type:Organization
Organization Name:STATE OF DELAWARE
Other - Org Name:CHRISTIANA WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-744-4700
Mailing Address - Street 1:417 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3635
Mailing Address - Country:US
Mailing Address - Phone:302-744-4849
Mailing Address - Fax:302-739-6627
Practice Address - Street 1:417 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3635
Practice Address - Country:US
Practice Address - Phone:302-744-4849
Practice Address - Fax:302-739-6627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000013819Medicaid