Healthcare Provider Details

I. General information

NPI: 1679174924
Provider Name (Legal Business Name): DIVINE LEISURE & ACTIVITY CENTER ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 W 4TH AVE STE 26
HIALEAH FL
33012-6606
US

IV. Provider business mailing address

5355 W 7TH CT
HIALEAH FL
33012-2518
US

V. Phone/Fax

Practice location:
  • Phone: 786-413-8657
  • Fax:
Mailing address:
  • Phone: 786-413-8657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. EMILENES DOMINGUEZ
Title or Position: OWNER
Credential:
Phone: 786-413-8657