Provider Demographics
NPI:1285679118
Name:DIVINE HOSPICE INC
Entity Type:Organization
Organization Name:DIVINE HOSPICE INC
Other - Org Name:PROFESSIONAL HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSOLOTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:817-268-1946
Mailing Address - Street 1:345 WESTPARK WAY
Mailing Address - Street 2:#101
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3913
Mailing Address - Country:US
Mailing Address - Phone:817-268-1946
Mailing Address - Fax:817-268-0722
Practice Address - Street 1:345 WESTPARK WAY
Practice Address - Street 2:#101
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3913
Practice Address - Country:US
Practice Address - Phone:817-268-1946
Practice Address - Fax:817-268-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008914251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012721Medicaid