Provider Demographics
NPI:1275655086
Name:GLORY DIVINE HOME CARE, INC
Entity Type:Organization
Organization Name:GLORY DIVINE HOME CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEDDRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-369-4111
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:NAPOLEONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70390-0867
Mailing Address - Country:US
Mailing Address - Phone:985-369-4111
Mailing Address - Fax:985-369-4110
Practice Address - Street 1:4589 A HWY 1
Practice Address - Street 2:
Practice Address - City:NAPOLEONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70390
Practice Address - Country:US
Practice Address - Phone:985-369-4111
Practice Address - Fax:985-369-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12505251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1597015OtherPROVIDER'S NUMBER