Provider Demographics
NPI:1073969317
Name:DEVINE ADULT FAMILY CARE HOME
Entity Type:Organization
Organization Name:DEVINE ADULT FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LOUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVELIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-515-2104
Mailing Address - Street 1:7913 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FLORIDA
Mailing Address - Zip Code:33319
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7913 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-1103
Practice Address - Country:US
Practice Address - Phone:954-515-2104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906841311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AOther311ZA0620X