Provider Demographics
NPI:1154818706
Name:FIRST DIVINE HOME HEALTHCARE AGENCY INC.
Entity Type:Organization
Organization Name:FIRST DIVINE HOME HEALTHCARE AGENCY INC.
Other - Org Name:FIRST DIVINE HOME HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUBONEMI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:512-870-7395
Mailing Address - Street 1:2612 BYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7614
Mailing Address - Country:US
Mailing Address - Phone:512-870-7395
Mailing Address - Fax:512-456-7450
Practice Address - Street 1:7901 CAMERON RD STE 302
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-3831
Practice Address - Country:US
Practice Address - Phone:512-775-6392
Practice Address - Fax:512-990-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010400251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158806705Medicaid