Provider Demographics
NPI:1396041687
Name:DIVINE HOME AND ADULT CARE SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE HOME AND ADULT CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-876-9882
Mailing Address - Street 1:PO BOX 16125
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-0125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 E MANNING ST
Practice Address - Street 2:SUITE A
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3998
Practice Address - Country:US
Practice Address - Phone:423-785-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000007989251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health