Provider Demographics
NPI:1780124537
Name:DIVINE FAVOUR HEALTHCARE LLC
Entity type:Organization
Organization Name:DIVINE FAVOUR HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUWAKEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMONIYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-738-2019
Mailing Address - Street 1:11 DARDEN CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8339
Mailing Address - Country:US
Mailing Address - Phone:480-738-2019
Mailing Address - Fax:
Practice Address - Street 1:11 DARDEN CT
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8339
Practice Address - Country:US
Practice Address - Phone:480-738-2019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care