Organization
DELTA LIFESTYLE SOLUTIONS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY HACKNEY FNP-BC (OWNER)
(304) 623-6300
Entity
Organization
Contact information
Practice address
109 TOLLEY DR, BRIDGEPORT, WV 26330-1669
(304) 623-6300
(304) 623-6302
Mailing address
PO BOX 4246, CLARKSBURG, WV 26302-4246
(304) 623-6300
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
207QA0401X
Addiction Medicine (Family Medicine) Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1639326747
—
WV
Enumeration date
11/10/2020
Last updated
11/05/2021
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