Healthcare Provider Details

I. General information

NPI: 1144784604
Provider Name (Legal Business Name): DIVINE HEALTHCARE AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 W VINE ST
KISSIMMEE FL
34741-4154
US

IV. Provider business mailing address

421 W VINE ST
KISSIMMEE FL
34741-4154
US

V. Phone/Fax

Practice location:
  • Phone: 407-724-1517
  • Fax:
Mailing address:
  • Phone: 407-724-1517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MONICA AJIBOLA
Title or Position: PRESIDENT
Credential:
Phone: 407-791-0093