1063690246 NPI number — DIVERSE FAMILY SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063690246 NPI number — DIVERSE FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSE FAMILY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063690246
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3020 PICKETT RD
Provider Second Line Business Mailing Address:
SUITE 135
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27705-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-544-5871
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 PICKETT RD
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27705-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-544-5871
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
MILLISENT
Authorized Official Title or Position:
CO-OWNER/QUALIFIED PROFESSIONAL
Authorized Official Telephone Number:
919-544-5871

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  302E00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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