Provider Demographics
NPI:1043365646
Name:DIVINE GUIDANCE INTEGRATIVE SERVICES
Entity type:Organization
Organization Name:DIVINE GUIDANCE INTEGRATIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-714-9056
Mailing Address - Street 1:2317 EXECUTIVE CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3762
Mailing Address - Country:US
Mailing Address - Phone:252-695-6040
Mailing Address - Fax:252-695-6026
Practice Address - Street 1:202 S WARREN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-2721
Practice Address - Country:US
Practice Address - Phone:252-752-0551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-074-181322D00000X
NCMHL-074-184322D00000X
NCMHL-074-185322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604166Medicaid
NC6604167Medicaid
NC6604099Medicaid
NC8301931BMedicaid