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General NPI Number Information
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NPI Number | 1639351703
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Entity Type | Organization
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Legal Business Name | DIVINE FAMILY CARE HOME
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Dates
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Enumeration Date | 11/30/2007
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Last Update Date | 11/30/2007
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Provider Practice Location Address
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Address Line | 113 JUSTICE ST
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City | LOUISBURG
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State | NC
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Zip | 27549-2331
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Country | US
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Telephone | 919-853-2700
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Fax | 919-853-7527
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Provider Business Mailing Address
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Address Line | 113 JUSTICE ST
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City | LOUISBURG
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State | NC
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Zip | 27549-2331
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Country | US
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Telephone | 919-853-2700
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Fax | 919-853-7527
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MR. CHRIS O ISIJOLA
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Credential |
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Telephone | 919-880-4619
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 035019
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License Number State | NC
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