Provider Demographics
NPI:1528556453
Name:DIVINECARELLC
Entity Type:Organization
Organization Name:DIVINECARELLC
Other - Org Name:DIVINECARELLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ORIKANNU SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-994-9937
Mailing Address - Street 1:16926 SW STEELE WAY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-8936
Mailing Address - Country:US
Mailing Address - Phone:971-222-9122
Mailing Address - Fax:
Practice Address - Street 1:16926 SW STEELE WAY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8936
Practice Address - Country:US
Practice Address - Phone:971-222-9122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-2330251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health