Provider Demographics
NPI:1245700871
Name:DELOATCH, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:DELOATCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1502
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4123 CEDAR SPRINGS ROAFD
Practice Address - Street 2:APT. 2332
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219
Practice Address - Country:US
Practice Address - Phone:214-206-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist