MEDICARE: GREATER DIVINE HOME CARE 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	:	1912881137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER DIVINE HOME CARE LLC

Provider Business Mailing Address
First Line	:	3201 YORKTOWN AVE STE 103
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-1474
Country	:	US
Telephone Number	:	919-623-7945
Fax Number	:	984-278-5248

Provider Business Practice Location Address
First Line	:	3201 YORKTOWN AVE STE 103
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-3455
Country	:	US
Telephone Number	:	919-623-7945
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHIRLETTA GASTON
Credential	:
Telephone Number	:	919-623-7945

Provider Enumeration Date	:	08/01/2025
Last Update Date	:	06/16/2026

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