Provider Demographics
NPI:1205234002
Name:DIVINE HEALTHCARE
Entity type:Organization
Organization Name:DIVINE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAKEBA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-216-7185
Mailing Address - Street 1:3856 NOBLE ST APT 1510
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-4949
Mailing Address - Country:US
Mailing Address - Phone:769-216-7185
Mailing Address - Fax:
Practice Address - Street 1:3856 NOBLE ST APT 1510
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-4949
Practice Address - Country:US
Practice Address - Phone:769-216-7185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health