Provider Demographics
NPI:1093306912
Name:DIVINE WALK IN HOME CARE
Entity Type:Organization
Organization Name:DIVINE WALK IN HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEER-WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-996-0455
Mailing Address - Street 1:PO BOX 1033
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-1033
Mailing Address - Country:US
Mailing Address - Phone:601-996-0455
Mailing Address - Fax:
Practice Address - Street 1:124 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3914
Practice Address - Country:US
Practice Address - Phone:769-204-3488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health