Healthcare Provider Details

I. General information

NPI: 1902567084
Provider Name (Legal Business Name): DIVINE HEART LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2022
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W SOUTHERN AVE STE 3
PHOENIX AZ
85041-4627
US

IV. Provider business mailing address

21903 S 187TH WAY
QUEEN CREEK AZ
85142-6463
US

V. Phone/Fax

Practice location:
  • Phone: 520-208-1970
  • Fax:
Mailing address:
  • Phone: 652-020-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: FORSTER OKOLI
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 520-208-1970