Provider Demographics
NPI:1518391259
Name:DIVINE HOME CARE, INC.
Entity Type:Organization
Organization Name:DIVINE HOME CARE, INC.
Other - Org Name:DIVINE HOSPICE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:BREDE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:320-231-9757
Mailing Address - Street 1:322 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3312
Mailing Address - Country:US
Mailing Address - Phone:320-231-9757
Mailing Address - Fax:320-231-9795
Practice Address - Street 1:322 2ND ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3312
Practice Address - Country:US
Practice Address - Phone:320-231-9757
Practice Address - Fax:320-231-9795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE HOME CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-29
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363063251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN241597Medicare UPIN