Provider Demographics
NPI:1689828485
Name:DIVINE CAREGIVERS
Entity Type:Organization
Organization Name:DIVINE CAREGIVERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-483-3466
Mailing Address - Street 1:9920 WENDT WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4523
Mailing Address - Country:US
Mailing Address - Phone:209-483-3466
Mailing Address - Fax:
Practice Address - Street 1:9920 WENDT WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4523
Practice Address - Country:US
Practice Address - Phone:209-483-3466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0900096452253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care