Healthcare Provider Details

I. General information

NPI: 1508050402
Provider Name (Legal Business Name): DIVERSIFIED COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S BATTLEGROUND AVE
KINGS MOUNTAIN NC
28086-3601
US

IV. Provider business mailing address

PO BOX 1593
KINGS MOUNTAIN NC
28086-1593
US

V. Phone/Fax

Practice location:
  • Phone: 704-739-3997
  • Fax: 704-739-6420
Mailing address:
  • Phone: 704-739-3997
  • Fax: 704-739-6420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. JOSEPHINE DOGAN
Title or Position: OWNER
Credential: BSW
Phone: 803-448-8417