Provider Demographics
NPI:1003150475
Name:DIVINE HEALTHCARE LLC
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NAKIA
Authorized Official - Middle Name:CASSELL
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-896-2449
Mailing Address - Street 1:3840 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:MS
Mailing Address - Zip Code:39066-9691
Mailing Address - Country:US
Mailing Address - Phone:601-896-2449
Mailing Address - Fax:
Practice Address - Street 1:3840 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:MS
Practice Address - Zip Code:39066-9691
Practice Address - Country:US
Practice Address - Phone:601-896-2449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-24
Last Update Date:2012-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP318307251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care