Provider Demographics
NPI:1245287721
Name:DETA CORPORATION
Entity type:Organization
Organization Name:DETA CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERMELINDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:DJONDO
Authorized Official - Suffix:
Authorized Official - Credentials:COLLEGE GRADUATE
Authorized Official - Phone:708-756-7440
Mailing Address - Street 1:3259 HOLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-5515
Mailing Address - Country:US
Mailing Address - Phone:708-756-7440
Mailing Address - Fax:708-756-7680
Practice Address - Street 1:3259 HOLEMAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-5515
Practice Address - Country:US
Practice Address - Phone:708-756-7440
Practice Address - Fax:708-756-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4369230001Medicare ID - Type UnspecifiedPROVIDER NUMBER