Healthcare Provider Details

I. General information

NPI: 1750521027
Provider Name (Legal Business Name): DIVINE REVITALIZATION MANAGEMENT INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 TRAILWOOD DR
DUDLEY NC
28333-9466
US

IV. Provider business mailing address

205 DELUCA RD
GOLDSBORO NC
27534-4417
US

V. Phone/Fax

Practice location:
  • Phone: 919-330-4601
  • Fax: 919-330-4601
Mailing address:
  • Phone: 919-751-1254
  • Fax: 919-751-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL-096-218
License Number StateNC

VIII. Authorized Official

Name: MS. ROCHELLE NICOLE HERRING
Title or Position: OWNER
Credential: BS
Phone: 919-396-2586