Provider Demographics
NPI:1417307521
Name:DIVINE HEALTH ACADEMY
Entity Type:Organization
Organization Name:DIVINE HEALTH ACADEMY
Other - Org Name:D & C HOME CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AFAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-448-0251
Mailing Address - Street 1:5633 MONROE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-5591
Mailing Address - Country:US
Mailing Address - Phone:704-566-2955
Mailing Address - Fax:704-512-0165
Practice Address - Street 1:1622B US HIGHWAY 52 N
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-9507
Practice Address - Country:US
Practice Address - Phone:704-982-5903
Practice Address - Fax:704-512-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2394251E00000X, 251J00000X, 253Z00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC2394Medicaid