Organization
DIVINE PRODIGY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MISS NIKKITRA SHYVONNE WILLIAMS (OWNER)
(252) 431-9115
Entity
Organization
Contact information
Practice address
117 CHURCH ST, 115 CARMEL RIDGE RD, HENDERSON, NC 27536-4226
(252) 431-9115
(252) 438-6140
Mailing address
PO BOX 2191, HENDERSON, NC 27536-2191
(252) 431-9115
(252) 438-6140
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
194
NC
Other
Enumeration date
08/19/2009
Last updated
09/02/2009
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