Provider Demographics
NPI:1114622099
Name:DIVINE GUARDIAN HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:DIVINE GUARDIAN HEALTH ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JODIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-514-0009
Mailing Address - Street 1:485C US HIGHWAY 1 S STE 100-24
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-3037
Mailing Address - Country:US
Mailing Address - Phone:914-514-0009
Mailing Address - Fax:
Practice Address - Street 1:485C US HIGHWAY 1 S STE 100-24
Practice Address - Street 2:
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-3037
Practice Address - Country:US
Practice Address - Phone:914-514-0009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-31
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251G00000XAgenciesHospice Care, Community Based
No251X00000XAgenciesSupports Brokerage
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty