Provider Demographics
NPI:1932599610
Name:DIVINE PRIVATE HOME CARE PROVIDER
Entity Type:Organization
Organization Name:DIVINE PRIVATE HOME CARE PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LATIFAT
Authorized Official - Middle Name:ABIMBOLA
Authorized Official - Last Name:OKE
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR IN NURSING
Authorized Official - Phone:678-517-5305
Mailing Address - Street 1:7317 DEXTER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1522
Mailing Address - Country:US
Mailing Address - Phone:678-517-5305
Mailing Address - Fax:
Practice Address - Street 1:7317 DEXTER DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1522
Practice Address - Country:US
Practice Address - Phone:678-517-5305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-R-1124251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health