Provider Demographics
NPI:1538678651
Name:DIVINE HERITAGE HEALTH HOME CARE AGENCY LLC
Entity Type:Organization
Organization Name:DIVINE HERITAGE HEALTH HOME CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-440-2462
Mailing Address - Street 1:5757 N LINCOLN AVE STE 23
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4729
Mailing Address - Country:US
Mailing Address - Phone:872-208-5385
Mailing Address - Fax:872-208-5354
Practice Address - Street 1:431 W WINTERGREEN RD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2394
Practice Address - Country:US
Practice Address - Phone:979-803-0032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENIOR HEALTH INFORMATION NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-20
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251300000X
IN251G00000X, 343900000X
MN251J00000X
TX282J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution
No251300000XAgenciesLocal Education Agency (LEA)
No251G00000XAgenciesHospice Care, Community Based
No251J00000XAgenciesNursing Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)