Healthcare Provider Details

I. General information

NPI: 1497857833
Provider Name (Legal Business Name): DIVINE KONCEPTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 ROCKINGHAM RD SUITE 12
ROCKINGHAM NC
28379-4983
US

IV. Provider business mailing address

PO BOX 462
ELLERBE NC
28338-0462
US

V. Phone/Fax

Practice location:
  • Phone: 910-417-4950
  • Fax: 910-417-4953
Mailing address:
  • Phone: 910-417-4950
  • Fax: 910-417-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberRES/CAP/CIS
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL-077-044
License Number StateNC

VIII. Authorized Official

Name: MRS. BRENDA T CAPEL
Title or Position: PRESIDENT/CEO
Credential: B.S./QP
Phone: 910-417-4950