Provider Demographics
NPI:1619113131
Name:DIVINE FAVOR INC,
Entity Type:Organization
Organization Name:DIVINE FAVOR INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO CASE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:NMN
Authorized Official - Last Name:FLEETWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:252-396-1551
Mailing Address - Street 1:1137 VIRGINIA BLVD
Mailing Address - Street 2:P.O, BOX 686
Mailing Address - City:MURFREESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27855-1129
Mailing Address - Country:US
Mailing Address - Phone:252-396-1551
Mailing Address - Fax:
Practice Address - Street 1:1137 VIRGINIA BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:NC
Practice Address - Zip Code:27855-1129
Practice Address - Country:US
Practice Address - Phone:252-396-1551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management