Provider Demographics
NPI:1962568626
Name:CHARLIE VAN DIVIERE LTD
Entity type:Organization
Organization Name:CHARLIE VAN DIVIERE LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAS.
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN DIVIERE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:706-285-2073
Mailing Address - Street 1:357 BOYCE GUIN RD
Mailing Address - Street 2:
Mailing Address - City:TIGNALL
Mailing Address - State:GA
Mailing Address - Zip Code:30668-3639
Mailing Address - Country:US
Mailing Address - Phone:706-285-2073
Mailing Address - Fax:706-285-2076
Practice Address - Street 1:357 BOYCE GUIN RD
Practice Address - Street 2:
Practice Address - City:TIGNALL
Practice Address - State:GA
Practice Address - Zip Code:30668-3639
Practice Address - Country:US
Practice Address - Phone:706-285-2073
Practice Address - Fax:706-285-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00462393 A&B332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00462393AMedicaid
GA00462393BMedicaid
GA00462393BMedicaid