Provider Demographics
NPI:1093168924
Name:DIVINITY HOME HEALTHCARE, LLC
Entity Type:Organization
Organization Name:DIVINITY HOME HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:GERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-543-1498
Mailing Address - Street 1:3829 CARDINAL OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-4251
Mailing Address - Country:US
Mailing Address - Phone:561-543-1498
Mailing Address - Fax:904-900-8113
Practice Address - Street 1:1734 KINGSLEY AVE STE 3
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4418
Practice Address - Country:US
Practice Address - Phone:904-900-8073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1093168924Medicaid