Provider Demographics
NPI:1578797569
Name:DIVINE HOMECARE LLC
Entity Type:Organization
Organization Name:DIVINE HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SERVICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-904-2377
Mailing Address - Street 1:751 S MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3258
Mailing Address - Country:US
Mailing Address - Phone:910-904-2377
Mailing Address - Fax:910-904-2477
Practice Address - Street 1:5511 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2057
Practice Address - Country:US
Practice Address - Phone:910-429-7481
Practice Address - Fax:910-429-7480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE HOMECARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3012251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601209Medicaid