Healthcare Provider Details

I. General information

NPI: 1639048366
Provider Name (Legal Business Name): LA MAIN DIVINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 SUNDOWN LN
CLERMONT FL
34711-2793
US

IV. Provider business mailing address

1521 SUNDOWN LN
CLERMONT FL
34711-2793
US

V. Phone/Fax

Practice location:
  • Phone: 352-988-9276
  • Fax:
Mailing address:
  • Phone: 352-988-9276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ALICA CHARLES
Title or Position: ADMINISTRATOR
Credential: CEO
Phone: 352-988-9276