Provider Demographics
NPI:1083336093
Name:DIVINE INDIVIDUALIZED SUPPORTS
Entity Type:Organization
Organization Name:DIVINE INDIVIDUALIZED SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:INMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-434-1856
Mailing Address - Street 1:703 ARONS CIR
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2534
Mailing Address - Country:US
Mailing Address - Phone:856-434-1856
Mailing Address - Fax:
Practice Address - Street 1:703 ARONS CIR
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2534
Practice Address - Country:US
Practice Address - Phone:856-434-1856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities