Provider Demographics
NPI:1003993197
Name:DIVINE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSAGIE
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:919-881-8041
Mailing Address - Street 1:1001 NAVAHO DR
Mailing Address - Street 2:SUITE 203-B
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7335
Mailing Address - Country:US
Mailing Address - Phone:919-881-8041
Mailing Address - Fax:919-881-8316
Practice Address - Street 1:1001 NAVAHO DR
Practice Address - Street 2:SUITE 203-B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7335
Practice Address - Country:US
Practice Address - Phone:919-881-8041
Practice Address - Fax:919-881-8316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC-3018251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND340-8383Medicaid
NC660-1281Medicaid