Provider Demographics
NPI:1619347705
Name:DIVINE CARE
Entity Type:Organization
Organization Name:DIVINE CARE
Other - Org Name:THE DIVINE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-412-3956
Mailing Address - Street 1:215 EXECUTIVE WAY
Mailing Address - Street 2:130
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2396
Mailing Address - Country:US
Mailing Address - Phone:972-947-3100
Mailing Address - Fax:972-947-3099
Practice Address - Street 1:215 EXECUTIVE WAY
Practice Address - Street 2:130
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2396
Practice Address - Country:US
Practice Address - Phone:972-947-3100
Practice Address - Fax:972-947-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016265251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX016265OtherLICENSED HOME HEALTH SERVICES, PERSONAL CARE SERVICES