Provider Demographics
NPI:1851531099
Name:DIVINE LIVING HOME CARE AGENCY
Entity Type:Organization
Organization Name:DIVINE LIVING HOME CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEANNA
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-625-9775
Mailing Address - Street 1:403 N JK POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-3128
Mailing Address - Country:US
Mailing Address - Phone:910-625-9775
Mailing Address - Fax:
Practice Address - Street 1:403 N JK POWELL BLVD
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3128
Practice Address - Country:US
Practice Address - Phone:910-625-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-28
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601861Medicaid