Provider Demographics
NPI:1235805847
Name:DIVINE CARE OF PORT CHARLOTTE
Entity Type:Organization
Organization Name:DIVINE CARE OF PORT CHARLOTTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVET
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLOWERS DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-626-5409
Mailing Address - Street 1:2532 STARLITE LN
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5653
Mailing Address - Country:US
Mailing Address - Phone:941-626-5409
Mailing Address - Fax:941-235-8770
Practice Address - Street 1:2532 STARLITE LN
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5653
Practice Address - Country:US
Practice Address - Phone:941-626-5409
Practice Address - Fax:941-235-8770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances