Provider Demographics
NPI:1841215712
Name:DIVINE HOME CARE INC
Entity Type:Organization
Organization Name:DIVINE HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BREDE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:320-231-9757
Mailing Address - Street 1:322 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-231-9757
Mailing Address - Fax:320-231-9795
Practice Address - Street 1:322 2ND ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-231-9757
Practice Address - Fax:320-231-9795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN510606100Medicaid
MN=========OtherFED