Provider Demographics
NPI:1386376754
Name:NEA DIVINE INTERVENTION INC
Entity type:Organization
Organization Name:NEA DIVINE INTERVENTION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZIQUE-GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-316-0234
Mailing Address - Street 1:4213 TERI DAWN CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7839
Mailing Address - Country:US
Mailing Address - Phone:870-206-4455
Mailing Address - Fax:
Practice Address - Street 1:2504 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6474
Practice Address - Country:US
Practice Address - Phone:870-206-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-25
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR01031991Medicaid