Provider Demographics
NPI:1578235016
Name:ITS IN THE DIVINE LLC
Entity Type:Organization
Organization Name:ITS IN THE DIVINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-205-4524
Mailing Address - Street 1:18115 LITTLEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1466
Mailing Address - Country:US
Mailing Address - Phone:313-205-4524
Mailing Address - Fax:
Practice Address - Street 1:607 SHELBY ST STE 700-1117
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-3268
Practice Address - Country:US
Practice Address - Phone:313-766-2020
Practice Address - Fax:231-216-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802633631Medicaid