Provider Demographics
NPI:1912292806
Name:DIVINE INTERVENTION HEALTHCARE, INC
Entity Type:Organization
Organization Name:DIVINE INTERVENTION HEALTHCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRENA
Authorized Official - Middle Name:ARMETTA
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:708-248-7662
Mailing Address - Street 1:4747 LINCOLN MALL DR
Mailing Address - Street 2:SUITE 502
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3811
Mailing Address - Country:US
Mailing Address - Phone:708-248-7662
Mailing Address - Fax:708-248-7682
Practice Address - Street 1:4747 LINCOLN MALL DR
Practice Address - Street 2:SUITE 502
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3811
Practice Address - Country:US
Practice Address - Phone:708-248-7662
Practice Address - Fax:708-248-7682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-19
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
148305Medicare PIN