Provider Demographics
NPI:1801310800
Name:DIVINE PATHWAYS
Entity type:Organization
Organization Name:DIVINE PATHWAYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:V
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-461-5763
Mailing Address - Street 1:10111 W CAPITOL DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10111 W CAPITOL DR STE 4
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-1335
Practice Address - Country:US
Practice Address - Phone:414-461-5763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health