Provider Demographics
NPI:1780386730
Name:DIVINE GRACE COUNTRY HOME LLC.
Entity type:Organization
Organization Name:DIVINE GRACE COUNTRY HOME LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-449-4285
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:BARODA
Mailing Address - State:MI
Mailing Address - Zip Code:49101-0243
Mailing Address - Country:US
Mailing Address - Phone:269-449-4285
Mailing Address - Fax:
Practice Address - Street 1:7720 WRIGHT RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-9071
Practice Address - Country:US
Practice Address - Phone:269-449-4285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home