Provider Demographics
NPI:1679194237
Name:DIVINE HEALING SENIOR & DISABLED SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE HEALING SENIOR & DISABLED SERVICES LLC
Other - Org Name:DECORKUS V ALLEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DECORKUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-274-7104
Mailing Address - Street 1:211 GAY ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-1646
Mailing Address - Country:US
Mailing Address - Phone:850-274-7104
Mailing Address - Fax:239-785-1707
Practice Address - Street 1:8866 HIGH BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343
Practice Address - Country:US
Practice Address - Phone:850-274-7104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021500500Medicaid
FL114242100Medicaid