Provider Demographics
NPI:1982999090
Name:DIVINE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:OMEREONYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-975-0121
Mailing Address - Street 1:4238 W HAWTHORNE TRACE RD APT 104
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4238 W HAWTHORNE TRACE RD APT 104
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1026
Practice Address - Country:US
Practice Address - Phone:414-975-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI126208-30313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX271904077OtherIRS