Provider Demographics
NPI:1326150343
Name:DIVINE HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE CORPORATION
Other - Org Name:DIVINE HEALTHCARE NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:OBI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-665-9795
Mailing Address - Street 1:856 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4807
Mailing Address - Country:US
Mailing Address - Phone:651-665-9795
Mailing Address - Fax:651-665-9796
Practice Address - Street 1:856 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4807
Practice Address - Country:US
Practice Address - Phone:651-665-9795
Practice Address - Fax:651-665-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN205335700251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1326150343Medicaid
MN181647OtherU CARE MINNESOTA
MN922134016OtherMHP: MINNESOTA HEALTH PLA
MN167251OtherUCARE
MN1Z68UNOtherBLUE CROSS BLUE SHIELD
MN5900021OtherMEDICA
MN65531OtherHEALTH PARTNERS
WI248055Medicare Oscar/Certification