=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043365646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE GUIDANCE INTEGRATIVE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 07/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 S WARREN ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-752-0551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2317 EXECUTIVE CIR SUITE B
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27834-3762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-695-6040
-----------------------------------------------------
Fax | 252-695-6026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. JEFFREY WARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-714-9056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-074-181
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-074-184
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL-074-185
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------