Provider Demographics
NPI:1760618474
Name:DIVINE HOME HEALTH CARE SERVICES
Entity Type:Organization
Organization Name:DIVINE HOME HEALTH CARE SERVICES
Other - Org Name:DIVINE HEALTH CARE SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINSTATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLASIMBO
Authorized Official - Middle Name:IFASEWA
Authorized Official - Last Name:ODUTAYO
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:817-350-4867
Mailing Address - Street 1:308, AUTUMN PARK
Mailing Address - Street 2:
Mailing Address - City:FORT-WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140
Mailing Address - Country:US
Mailing Address - Phone:817-350-4867
Mailing Address - Fax:
Practice Address - Street 1:308, AUTUMN PARK
Practice Address - Street 2:
Practice Address - City:FORT-WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140
Practice Address - Country:US
Practice Address - Phone:817-350-4867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health