Provider Demographics
NPI:1689246183
Name:DIVINE PROVIDENCE HOMES LLC
Entity Type:Organization
Organization Name:DIVINE PROVIDENCE HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:BORRA
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:651-785-6880
Mailing Address - Street 1:1445 WINTHROP ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3065
Mailing Address - Country:US
Mailing Address - Phone:651-327-1445
Mailing Address - Fax:651-327-1445
Practice Address - Street 1:1445 WINTHROP ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-3065
Practice Address - Country:US
Practice Address - Phone:651-327-1445
Practice Address - Fax:651-327-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility