Provider Demographics
NPI:1639351703
Name:DIVINE FAMILY CARE HOME
Entity Type:Organization
Organization Name:DIVINE FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:O
Authorized Official - Last Name:ISIJOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-880-4619
Mailing Address - Street 1:113 JUSTICE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-2331
Mailing Address - Country:US
Mailing Address - Phone:919-853-2700
Mailing Address - Fax:919-853-7527
Practice Address - Street 1:113 JUSTICE ST
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2331
Practice Address - Country:US
Practice Address - Phone:919-853-2700
Practice Address - Fax:919-853-7527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC035019310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility