Provider Demographics
NPI:1669924866
Name:DIVINE SUPPORTS SERVICES
Entity type:Organization
Organization Name:DIVINE SUPPORTS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLUFUNMILAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:BALOGUN-VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:484-358-5535
Mailing Address - Street 1:3954 STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-2723
Mailing Address - Country:US
Mailing Address - Phone:484-358-5535
Mailing Address - Fax:
Practice Address - Street 1:3954 STRATFORD RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-2723
Practice Address - Country:US
Practice Address - Phone:484-358-5535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN600719251J00000X, 251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103220771OtherODP