Provider Demographics
NPI:1790113306
Name:DIVINE ANGELS SERVICES
Entity Type:Organization
Organization Name:DIVINE ANGELS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-316-5224
Mailing Address - Street 1:10300 SW 72ND STREET
Mailing Address - Street 2:SUITE 460-7
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-1828
Mailing Address - Country:US
Mailing Address - Phone:786-316-5224
Mailing Address - Fax:305-392-1828
Practice Address - Street 1:10300 SW 72ND STREET
Practice Address - Street 2:SUITE 460-7
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-1828
Practice Address - Country:US
Practice Address - Phone:786-316-5224
Practice Address - Fax:305-275-1828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL230135253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000287901Medicaid
FL000287900OtherDEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED WAIVER SERVICES