Provider Demographics
NPI:1356482970
Name:STATE OF DELAWARE
Entity type:Organization
Organization Name:STATE OF DELAWARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR FDS
Authorized Official - Prefix:
Authorized Official - First Name:JENA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-255-2743
Mailing Address - Street 1:1901 N DUPONT HWY
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-1160
Mailing Address - Country:US
Mailing Address - Phone:302-255-2700
Mailing Address - Fax:
Practice Address - Street 1:1901 N DUPONT HWY
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-1160
Practice Address - Country:US
Practice Address - Phone:302-255-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEHSPTL-009283Q00000X, 310500000X
310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEHSPTL-009OtherHOSPITAL LICENSE
DE0000121964Medicaid
DE0000151425Medicaid
084001Medicare ID - Type Unspecified