| Dvine Systems Ga Llc | |
|
255 Racetrack Rd 26 Mcdonough GA 30252-6834 | |
| (678) 212-5146 | |
| (678) 831-3554 |
| Full Name | Dvine Systems Ga Llc |
|---|---|
| Speciality | Counselor |
| Location | 255 Racetrack Rd, Mcdonough, Georgia |
| Authorized Official Name and Position | Glendora Dvine (C.E.O.) |
| Authorized Official Contact | 6782125146 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Dvine Systems Ga Llc 255 Racetrack Rd #26 Mcdonough GA 30252-6834 Ph: (678) 212-5146 | Dvine Systems Ga Llc 255 Racetrack Rd 26 Mcdonough GA 30252-6834 Ph: (678) 212-5146 |
| NPI Number | 1396065793 |
|---|---|
| Provider Enumeration Date | 06/08/2010 |
| Last Update Date | 11/11/2014 |
| Medicare PECOS PAC ID | 3971818196 |
|---|---|
| Medicare Enrollment ID | O20150818004056 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396065793 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | LPC006210 (Georgia) | Primary |
| Provider Name | Glendora Dvine |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1144540535 PECOS PAC ID: 0547575763 Enrollment ID: I20240405003058 |
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