Provider Demographics
NPI:1396214144
Name:A DIVINE MIRACLE ADULT DAY CENTER
Entity Type:Organization
Organization Name:A DIVINE MIRACLE ADULT DAY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:BSN/RN
Authorized Official - Phone:615-891-7412
Mailing Address - Street 1:331 GALLATIN PIKE S STE 1
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-4052
Mailing Address - Country:US
Mailing Address - Phone:615-830-2430
Mailing Address - Fax:
Practice Address - Street 1:331 GALLATIN PIKE S STE 1
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4052
Practice Address - Country:US
Practice Address - Phone:615-830-2430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014710Medicaid