Healthcare Provider Details

I. General information

NPI: 1487054300
Provider Name (Legal Business Name): DIVINE HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 GRANT ST APT 3
DOTHAN AL
36301-3807
US

IV. Provider business mailing address

802 GRANT ST APT 3
DOTHAN AL
36301-3807
US

V. Phone/Fax

Practice location:
  • Phone: 334-405-5881
  • Fax:
Mailing address:
  • Phone: 334-405-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DERRICK O TILLER
Title or Position: OWNER
Credential:
Phone: 334-405-5881