Provider Demographics
NPI:1144784604
Name:DIVINE HEALTHCARE AGENCY LLC
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:AJIBOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-791-0093
Mailing Address - Street 1:421 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4154
Mailing Address - Country:US
Mailing Address - Phone:407-724-1517
Mailing Address - Fax:
Practice Address - Street 1:421 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4154
Practice Address - Country:US
Practice Address - Phone:407-724-1517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care