Provider Demographics
NPI:1790258523
Name:DIVINE LIFE INSTITUTE LLC
Entity Type:Organization
Organization Name:DIVINE LIFE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BELIZAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-381-9007
Mailing Address - Street 1:500 N RAINBOW BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1061
Mailing Address - Country:US
Mailing Address - Phone:978-540-5222
Mailing Address - Fax:185-542-0689
Practice Address - Street 1:75 ARLINGTON ST STE 500
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3936
Practice Address - Country:US
Practice Address - Phone:978-381-9007
Practice Address - Fax:855-420-6895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No253Z00000XAgenciesIn Home Supportive Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home