MEDICARE: DIVINE KIMAH I

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	374U00000X	Home Health Aide	HHA10240	DC

General Provider Information

NPI Number	:	1508274051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVINE KIMAH I

Provider Business Mailing Address
First Line	:	7837 RIVERDALE RD
Second Line	:	APT 302
City	:	NEW CARROLLTON
State	:	MD
Zip	:	20784-4020
Country	:	US
Telephone Number	:	240-264-9850
Fax Number	:

Provider Business Practice Location Address
First Line	:	7837 RIVERDALE RD
Second Line	:	APT 302
City	:	NEW CARROLLTON
State	:	MD
Zip	:	20784-4020
Country	:	US
Telephone Number	:	240-264-9850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/29/2014

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