Provider Demographics
NPI:1730113234
Name:DIVINE PROVIDENCE HEATLH CENTER INC.
Entity Type:Organization
Organization Name:DIVINE PROVIDENCE HEATLH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VERSCHELDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-694-2010
Mailing Address - Street 1:312 E GEORGE ST
Mailing Address - Street 2:PO BOX 136
Mailing Address - City:IVANHOE
Mailing Address - State:MN
Mailing Address - Zip Code:56142-9707
Mailing Address - Country:US
Mailing Address - Phone:507-694-1414
Mailing Address - Fax:
Practice Address - Street 1:312 E GEORGE ST
Practice Address - Street 2:
Practice Address - City:IVANHOE
Practice Address - State:MN
Practice Address - Zip Code:56142-9707
Practice Address - Country:US
Practice Address - Phone:507-694-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331268251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN247197Medicare ID - Type UnspecifiedHOME HEATLH