Provider Demographics
NPI:1508514696
Name:DIVINELY GIFTED HOME CARE SERVICES LLC
Entity Type:Organization
Organization Name:DIVINELY GIFTED HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TISHARAH
Authorized Official - Middle Name:ANTIONETTE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-313-2035
Mailing Address - Street 1:4238 WILMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3139
Mailing Address - Country:US
Mailing Address - Phone:216-313-2035
Mailing Address - Fax:
Practice Address - Street 1:4238 WILMINGTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3139
Practice Address - Country:US
Practice Address - Phone:216-313-2035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINELY GIFTED HOME CARE SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRY000595Medicaid