Provider Demographics
NPI:1083006647
Name:DIVINE GRACE IN-HOME & PRIVATE HEALTHCARE SERVICE
Entity type:Organization
Organization Name:DIVINE GRACE IN-HOME & PRIVATE HEALTHCARE SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JR
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-796-0734
Mailing Address - Street 1:3535 S WILMINGTON ST STE 202
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-3512
Mailing Address - Country:US
Mailing Address - Phone:919-796-0734
Mailing Address - Fax:
Practice Address - Street 1:3535 S WILMINGTON ST STE 202
Practice Address - Street 2:3535 SOUTH WILMINGTON STREET SUITE 202
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-3512
Practice Address - Country:US
Practice Address - Phone:919-796-0734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE GRACE IN-HOME & PRIVATE HEALTHCARE SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC4729251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC150081Medicaid