Provider Demographics
NPI:1972266955
Name:DIVINE GROUP HOME LLC
Entity Type:Organization
Organization Name:DIVINE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DIVINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-939-0573
Mailing Address - Street 1:40352 W MOLLY LN
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-5158
Mailing Address - Country:US
Mailing Address - Phone:480-939-0573
Mailing Address - Fax:
Practice Address - Street 1:40352 W MOLLY LN # A
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5158
Practice Address - Country:US
Practice Address - Phone:480-939-0573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health