Provider Demographics
NPI:1518138080
Name:ALLAM DALATI
Entity type:Organization
Organization Name:ALLAM DALATI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DALATI
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:707-465-1111
Mailing Address - Street 1:PO BOX 1972
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-1972
Mailing Address - Country:US
Mailing Address - Phone:479-685-0941
Mailing Address - Fax:479-621-9960
Practice Address - Street 1:1080 MASON MALL STE 6C
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4335
Practice Address - Country:US
Practice Address - Phone:707-465-1111
Practice Address - Fax:479-621-9960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4086630002Medicare NSC