Provider Demographics
NPI:1295394377
Name:DIVINITY COMMUNITY LIVING, INC.
Entity Type:Organization
Organization Name:DIVINITY COMMUNITY LIVING, INC.
Other - Org Name:DCL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-462-4513
Mailing Address - Street 1:405 BRIARWOOD DR STE 108Q
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3032
Mailing Address - Country:US
Mailing Address - Phone:769-572-7327
Mailing Address - Fax:
Practice Address - Street 1:405 BRIARWOOD DR STE 108Q
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3032
Practice Address - Country:US
Practice Address - Phone:769-572-7327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-11
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care