Provider Demographics
NPI:1356676746
Name:DVINE CARE
Entity Type:Organization
Organization Name:DVINE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-810-5788
Mailing Address - Street 1:1017 HANEY RD. SUITE.C
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666
Mailing Address - Country:US
Mailing Address - Phone:601-810-5788
Mailing Address - Fax:
Practice Address - Street 1:2102 TRADEWIND DR
Practice Address - Street 2:SUITE 172
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-3309
Practice Address - Country:US
Practice Address - Phone:601-810-5788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 253Z00000X
MS251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health