Provider Demographics
NPI:1831545268
Name:DIVINE CENTER, INC
Entity type:Organization
Organization Name:DIVINE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO(OPERATIONS)
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-721-6535
Mailing Address - Street 1:8351 S MARQUETTE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2022
Mailing Address - Country:US
Mailing Address - Phone:773-721-6535
Mailing Address - Fax:773-721-7065
Practice Address - Street 1:8351 S MARQUETTE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2022
Practice Address - Country:US
Practice Address - Phone:773-721-6535
Practice Address - Fax:773-721-7065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL200400002C320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3000006OtherDHS DDD
IL7094638OtherDHS DDD