Provider Demographics
NPI:1407087166
Name:DIVINE CARE SERVICES, LLC
Entity Type:Organization
Organization Name:DIVINE CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-717-2169
Mailing Address - Street 1:3709 LIVE OAK LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4152
Mailing Address - Country:US
Mailing Address - Phone:252-717-2169
Mailing Address - Fax:
Practice Address - Street 1:500 C DEXTER STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5302
Practice Address - Country:US
Practice Address - Phone:252-215-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health