Provider Demographics
NPI:1972805919
Name:DELTA CENTER, INC
Entity Type:Organization
Organization Name:DELTA CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-734-2665
Mailing Address - Street 1:130 RICHLAND TER
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:IL
Mailing Address - Zip Code:62964-1233
Mailing Address - Country:US
Mailing Address - Phone:618-734-2665
Mailing Address - Fax:618-734-1999
Practice Address - Street 1:130 RICHLAND TER
Practice Address - Street 2:
Practice Address - City:MOUNDS
Practice Address - State:IL
Practice Address - Zip Code:62964-1233
Practice Address - Country:US
Practice Address - Phone:618-734-2665
Practice Address - Fax:618-734-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL094500030261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)