Provider Demographics
NPI:1255167979
Name:ASONG, DIVINE
Entity type:Individual
Prefix:MR
First Name:DIVINE
Middle Name:
Last Name:ASONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 E STAGECOACH TRL
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28090-9553
Mailing Address - Country:US
Mailing Address - Phone:704-538-3052
Mailing Address - Fax:704-312-6164
Practice Address - Street 1:1020 E STAGECOACH TRL
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:NC
Practice Address - Zip Code:28090-9553
Practice Address - Country:US
Practice Address - Phone:704-538-3052
Practice Address - Fax:704-312-6164
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home