Provider Demographics
NPI:1821841784
Name:A DIVINE LIFESTYLE
Entity Type:Organization
Organization Name:A DIVINE LIFESTYLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMIA
Authorized Official - Middle Name:ANITA
Authorized Official - Last Name:HASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:984-514-5259
Mailing Address - Street 1:5530 TABBS CREEK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-5906
Mailing Address - Country:US
Mailing Address - Phone:984-514-5259
Mailing Address - Fax:
Practice Address - Street 1:5530 TABBS CREEK CHURCH RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-5906
Practice Address - Country:US
Practice Address - Phone:984-514-5259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities