Provider Demographics
NPI:1871000141
Name:DIVINE AT HILLSBORO ST INC.
Entity Type:Organization
Organization Name:DIVINE AT HILLSBORO ST INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:O
Authorized Official - Last Name:ISIJOLA
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:919-880-4619
Mailing Address - Street 1:502 N HILLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-7779
Mailing Address - Country:US
Mailing Address - Phone:919-880-4619
Mailing Address - Fax:
Practice Address - Street 1:502 N HILLSBORO ST
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27596-7779
Practice Address - Country:US
Practice Address - Phone:919-880-4619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home