Provider Demographics
NPI:1710581608
Name:DIVINE RESIDENTIAL LIVING
Entity Type:Organization
Organization Name:DIVINE RESIDENTIAL LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-527-1329
Mailing Address - Street 1:4393 BLACKS RD SW
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:OH
Mailing Address - Zip Code:43025-9774
Mailing Address - Country:US
Mailing Address - Phone:614-592-6096
Mailing Address - Fax:
Practice Address - Street 1:209 BOYD RD
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8237
Practice Address - Country:US
Practice Address - Phone:937-309-5125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0267919Medicaid