Provider Demographics
NPI:1376710087
Name:DIVINE KONCEPTS, INC
Entity Type:Organization
Organization Name:DIVINE KONCEPTS, INC
Other - Org Name:NLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:T
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-942-8410
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28026-1310
Mailing Address - Country:US
Mailing Address - Phone:704-942-8410
Mailing Address - Fax:
Practice Address - Street 1:451 FAITH DR SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-6929
Practice Address - Country:US
Practice Address - Phone:704-942-8410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE KONCEPTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC049-143320800000X
NC013-033320800000X
NC1205093440320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603600Medicaid
NC6603599Medicaid
NC1205093440OtherNPI