Provider Demographics
NPI:1093248973
Name:LOVE AND DIVINE HOME CARE
Entity Type:Organization
Organization Name:LOVE AND DIVINE HOME CARE
Other - Org Name:A LOVING AND DIVINE HOME CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:IVANCICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-945-0241
Mailing Address - Street 1:303 OAK CANYON WAY
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-1855
Mailing Address - Country:US
Mailing Address - Phone:916-932-4883
Mailing Address - Fax:
Practice Address - Street 1:303 OAK CANYON WAY
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-1855
Practice Address - Country:US
Practice Address - Phone:916-932-4883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABUNDANT LIVING HOME CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347005677311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)