Provider Demographics
NPI:1053075259
Name:LIVING DIVINE HOME CARE LLC
Entity Type:Organization
Organization Name:LIVING DIVINE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKS-DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-866-8177
Mailing Address - Street 1:2455 W SERGEANT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-4135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2455 W SERGEANT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-4135
Practice Address - Country:US
Practice Address - Phone:215-399-2788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care