# DELTA LIFESTYLE SOLUTIONS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619579208
- **Authorized official:** MARY HACKNEY FNP-BC (OWNER)
- **Authorized official phone:** (304) 623-6300

## Contact information

- **Practice address:** 109 TOLLEY DR, BRIDGEPORT, WV 26330-1669
- **Practice address phone:** (304) 623-6300
- **Practice address fax:** (304) 623-6302
- **Mailing address:** PO BOX 4246, CLARKSBURG, WV 26302-4246
- **Mailing address phone:** (304) 623-6300

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207QA0401X | Addiction Medicine (Family Medicine) Physician | — | NULL | — |
| 207QA0401X | Addiction Medicine (Family Medicine) Physician | — | — | — |

## Other

- **Enumeration date:** 11/10/2020
- **Last updated:** 11/05/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1639326747 | — | WV |