Provider Demographics
NPI:1154420362
Name:ABSOLUTELY DIVINE HOME CARE AGENCY, INC.
Entity type:Organization
Organization Name:ABSOLUTELY DIVINE HOME CARE AGENCY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-485-8463
Mailing Address - Street 1:PO BOX 35781
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-0781
Mailing Address - Country:US
Mailing Address - Phone:910-485-8463
Mailing Address - Fax:
Practice Address - Street 1:3530 BOONE TAIL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-2830
Practice Address - Country:US
Practice Address - Phone:910-485-8463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABSOLUTELY DIVINE HOME CARE AGENCY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 253Z00000X
NCHC3037251E00000X, 251J00000X, 332B00000X, 374U00000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251J00000XAgenciesNursing Care
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408515Medicaid
NC6601297Medicaid
NC7100631Medicaid
NC3408515Medicaid