Provider Demographics
NPI:1235584558
Name:DIVINE HEALTH CARE SERVICE
Entity Type:Organization
Organization Name:DIVINE HEALTH CARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-869-1330
Mailing Address - Street 1:2940 YOUREE DR
Mailing Address - Street 2:STEA
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3657
Mailing Address - Country:US
Mailing Address - Phone:318-869-1330
Mailing Address - Fax:318-869-2720
Practice Address - Street 1:2940 YOUREE DR
Practice Address - Street 2:STEA
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3657
Practice Address - Country:US
Practice Address - Phone:318-869-1330
Practice Address - Fax:318-869-2720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)