MEDICARE: DIVINE LOVING ANGELS AFFORDABLE CAREGIVERS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1275140691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE LOVING ANGELS AFFORDABLE CAREGIVERS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 812
Second Line	:
City	:	ELLENDALE
State	:	TN
Zip	:	38029-0812
Country	:	US
Telephone Number	:	901-606-1784
Fax Number	:	901-443-5090

Provider Business Practice Location Address
First Line	:	8202 ROCKBRIDGE RD
Second Line	:
City	:	BARTLETT
State	:	TN
Zip	:	38002-4768
Country	:	US
Telephone Number	:	901-606-1784
Fax Number	:	901-443-5090

Authorized Official
Title or Position	:	OWNER
Name	:	CASSANDRA MILLER
Credential	:
Telephone Number	:	901-606-1784

Provider Enumeration Date	:	09/29/2020
Last Update Date	:	06/28/2021

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