Provider Demographics
NPI:1902003767
Name:DIVINE MERCY HOSPICE, INC
Entity Type:Organization
Organization Name:DIVINE MERCY HOSPICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MERCEDITHAS
Authorized Official - Middle Name:HIPOLITO
Authorized Official - Last Name:LIWANAG
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:909-986-6715
Mailing Address - Street 1:5589 BROOKS ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-4519
Mailing Address - Country:US
Mailing Address - Phone:909-986-6715
Mailing Address - Fax:909-986-6793
Practice Address - Street 1:5589 BROOKS ST
Practice Address - Street 2:UNIT B
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-4519
Practice Address - Country:US
Practice Address - Phone:909-986-6715
Practice Address - Fax:909-986-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000483251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-1571Medicare PIN