1619347705 NPI number — DIVINE CARE

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 1619347705 NPI number — DIVINE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE CARE
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:
6
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:
1619347705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 EXECUTIVE WAY
Provider Second Line Business Mailing Address:
130
Provider Business Mailing Address City Name:
DESOTO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75115-2396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-947-3100
Provider Business Mailing Address Fax Number:
972-947-3099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 EXECUTIVE WAY
Provider Second Line Business Practice Location Address:
130
Provider Business Practice Location Address City Name:
DESOTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75115-2396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-947-3100
Provider Business Practice Location Address Fax Number:
972-947-3099
Provider Enumeration Date:
10/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCQUEEN
Authorized Official First Name:
MERCEDES
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
817-412-3956

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  016265 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016265 . This is a "LICENSED HOME HEALTH SERVICES, PERSONAL CARE SERVICES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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