Provider Demographics
NPI:1962557561
Name:STATE OF DELAWARE-STOCKLEY
Entity type:Organization
Organization Name:STATE OF DELAWARE-STOCKLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOCIAL SERVICE CHIEF ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:F
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-741-9349
Mailing Address - Street 1:26351 PATRIOTS WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-2575
Mailing Address - Country:US
Mailing Address - Phone:302-933-3000
Mailing Address - Fax:302-934-1376
Practice Address - Street 1:26351 PATRIOTS WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2575
Practice Address - Country:US
Practice Address - Phone:302-933-3000
Practice Address - Fax:302-934-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1047315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000031813Medicaid