Provider Demographics
NPI:1598997959
Name:DIVINE PRODIGY LLC
Entity Type:Organization
Organization Name:DIVINE PRODIGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NIKKITRA
Authorized Official - Middle Name:SHYVONNE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-431-9115
Mailing Address - Street 1:PO BOX 2191
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2191
Mailing Address - Country:US
Mailing Address - Phone:252-431-9115
Mailing Address - Fax:252-438-6140
Practice Address - Street 1:117 CHURCH ST
Practice Address - Street 2:115 CARMEL RIDGE RD
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4226
Practice Address - Country:US
Practice Address - Phone:252-431-9115
Practice Address - Fax:252-438-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC194320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness