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NPI Code Detail

MEDICARE: DIVINE PRODIGY LLC

MEDICARE: DIVINE PRODIGY LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1320800000XMental Illness Community Based Residential Treatment Facility194NC

General Provider Information

NPI Number : 1598997959
Entity Type Code : Organization
Provider Name (Legal Business Name) : DIVINE PRODIGY LLC
Provider Business Mailing Address
First Line : PO BOX 2191
Second Line :
City : HENDERSON
State : NC
Zip : 27536-2191
Country : US
Telephone Number : 252-431-9115
Fax Number : 252-438-6140
Provider Business Practice Location Address
First Line : 117 CHURCH ST
Second Line : 115 CARMEL RIDGE RD
City : HENDERSON
State : NC
Zip : 27536-4226
Country : US
Telephone Number : 252-431-9115
Fax Number : 252-438-6140
Authorized Official
Title or Position : OWNER
Name : MISS NIKKITRA SHYVONNE WILLIAMS
Credential :
Telephone Number : 252-431-9115
Provider Enumeration Date : 08/19/2009
Last Update Date : 09/02/2009

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Directions to “DIVINE PRODIGY LLC ” Practice Location

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