Healthcare Provider Details

I. General information

NPI: 1417307521
Provider Name (Legal Business Name): DIVINE HEALTH ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622B US HIGHWAY 52 N
ALBEMARLE NC
28001-9507
US

IV. Provider business mailing address

5633 MONROE RD
CHARLOTTE NC
28212-5591
US

V. Phone/Fax

Practice location:
  • Phone: 704-982-5903
  • Fax: 704-512-0165
Mailing address:
  • Phone: 704-566-2955
  • Fax: 704-512-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC2394
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberHC2394
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHC2394
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberHC2394
License Number StateNC

VIII. Authorized Official

Name: DORIS AFAM
Title or Position: PRESIDENT
Credential:
Phone: 803-448-0251