Provider Demographics
NPI:1639663719
Name:DIVINE HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-532-2021
Mailing Address - Street 1:12681 TREEYARD LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1440
Mailing Address - Country:US
Mailing Address - Phone:314-659-6254
Mailing Address - Fax:
Practice Address - Street 1:12681 TREEYARD LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1440
Practice Address - Country:US
Practice Address - Phone:314-659-6254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO25320840251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health