Provider Demographics
NPI:1619033149
Name:CHAS VAN DIVIERE LTD
Entity Type:Organization
Organization Name:CHAS VAN DIVIERE LTD
Other - Org Name:DIVERES HOME SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN DIVIERE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:706-285-2073
Mailing Address - Street 1:357 BOYCE GUIN RD
Mailing Address - Street 2:
Mailing Address - City:TIGNALL
Mailing Address - State:GA
Mailing Address - Zip Code:30668
Mailing Address - Country:US
Mailing Address - Phone:706-285-2073
Mailing Address - Fax:706-285-2076
Practice Address - Street 1:357 BOYCE GUIN RD
Practice Address - Street 2:
Practice Address - City:TIGNALL
Practice Address - State:GA
Practice Address - Zip Code:30668
Practice Address - Country:US
Practice Address - Phone:706-285-2073
Practice Address - Fax:706-285-2076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAS VAN DIVIERE LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-29
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00530406AMedicaid