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General NPI Number Information
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NPI Number | 1851692545
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Entity Type | Organization
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Legal Business Name | DIVINE CARE 1962
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Dates
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Enumeration Date | 11/11/2010
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Last Update Date | 11/11/2010
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Provider Practice Location Address
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Address Line | 1962 NEPTUNE DR
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City | AUGUSTA
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State | GA
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Zip | 30906-5703
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Country | US
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Telephone | 706-798-2289
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Fax | 706-792-6228
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Provider Business Mailing Address
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Address Line | 1962 NEPTUNE DR
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City | AUGUSTA
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State | GA
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Zip | 30906-5703
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Country | US
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Telephone | 706-798-2289
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Fax | 706-792-6228
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOSEPH SHANKS
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Credential |
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Telephone | 706-798-2289
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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 | 121-01-459-1
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License Number State | GA
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