MEDICARE: DIVERSE WELLNESS SOLUTIONS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	0261495-01	NC
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	0261495-01	NC
3	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	0261495-01	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	NC1277A203	OTHER	NC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	527619	OTHER	NC	VALUE OPTIONS
5	10079	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1912299173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSE WELLNESS SOLUTIONS INC

Provider Business Mailing Address
First Line	:	7155 SUNSET LAKE RD
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-8638
Country	:	US
Telephone Number	:	919-838-0804
Fax Number	:	919-838-1219

Provider Business Practice Location Address
First Line	:	7155 SUNSET LAKE RD
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-8638
Country	:	US
Telephone Number	:	919-838-0804
Fax Number	:	919-838-1219

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MRS. KIMBALL JANE-MARIE SARGENT
Credential	:	MSN, PMHCNS-BC
Telephone Number	:	919-838-0804

Provider Enumeration Date	:	05/06/2011
Last Update Date	:	01/06/2016

Similar Medicare Providers

1174570808 — MRS. KIMBALL JANE-MARIE SARGENT MSN, PMHCNS-BC
Practice Location Address:

7155 SUNSET LAKE RD
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1558220996 — SOUL CARE PSYCHIATRY PLLC
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1174144414 — DR. DEANNA SIPES PT, DPT
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Directions to “DIVERSE WELLNESS SOLUTIONS INC ” Practice Location

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