Provider Demographics
NPI:1699274860
Name:DIVINE INTERVENTION TREATMENT FACILITY LLC
Entity type:Organization
Organization Name:DIVINE INTERVENTION TREATMENT FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERIONE
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-415-9371
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:VIOLET
Mailing Address - State:LA
Mailing Address - Zip Code:70092-0259
Mailing Address - Country:US
Mailing Address - Phone:504-415-9371
Mailing Address - Fax:
Practice Address - Street 1:5665 6TH ST
Practice Address - Street 2:
Practice Address - City:VIOLET
Practice Address - State:LA
Practice Address - Zip Code:70092-3040
Practice Address - Country:US
Practice Address - Phone:504-415-9371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)