Divine Prodigy LLC

Primary specialty

Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X

License

194 Issued in NC

Legal business name

DIVINE PRODIGY LLC

Practice address

117 Church St
115 Carmel Ridge Rd
Henderson, NC 27536-4226

Phone

(252) 431-9115

Fax

(252) 438-6140

NPI assigned

Aug 19, 2009

Last updated

Sep 2, 2009By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Miss Nikkitra Shyvonne Williams

Title

Owner

Phone

(252) 431-9115

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1250640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1251849600000",
    "number": "1598997959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2191",
            "city": "HENDERSON",
            "state": "NC",
            "postal_code": "275362191",
            "telephone_number": "252-431-9115",
            "fax_number": "252-438-6140"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "117 CHURCH ST",
            "address_2": "115 CARMEL RIDGE RD",
            "city": "HENDERSON",
            "state": "NC",
            "postal_code": "275364226",
            "telephone_number": "252-431-9115",
            "fax_number": "252-438-6140"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVINE PRODIGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-19",
        "last_updated": "2009-09-02",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "NIKKITRA",
        "authorized_official_middle_name": "SHYVONNE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "252-431-9115",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "NC",
            "license": "194",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mental Illness Community Based Residential Treatment Facility in Henderson, NC
• Providers in Henderson, NC by specialty
• Mental Illness Community Based Residential Treatment Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.