Provider Demographics
NPI:1326703232
Name:DIVINE LIGHT HOSPICE LLC
Entity Type:Organization
Organization Name:DIVINE LIGHT HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:770-696-1703
Mailing Address - Street 1:5750 BROOK HOLLOW PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-3515
Mailing Address - Country:US
Mailing Address - Phone:770-696-1703
Mailing Address - Fax:470-226-3371
Practice Address - Street 1:5750 BROOK HOLLOW PKWY STE 104
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-3515
Practice Address - Country:US
Practice Address - Phone:770-696-1703
Practice Address - Fax:470-226-3371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based