Provider Demographics
NPI:1619330974
Name:DIVINE ROYAL CARE, LLC
Entity Type:Organization
Organization Name:DIVINE ROYAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:O
Authorized Official - Last Name:WAGIDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-695-6684
Mailing Address - Street 1:10730 E BETHANY DR STE 185
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-2690
Mailing Address - Country:US
Mailing Address - Phone:303-695-6684
Mailing Address - Fax:303-856-3389
Practice Address - Street 1:10730 E BETHANY DR STE 185
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-2690
Practice Address - Country:US
Practice Address - Phone:303-695-6684
Practice Address - Fax:303-856-3389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14689740253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14689740Medicaid