Healthcare Provider Details

I. General information

NPI: 1417457607
Provider Name (Legal Business Name): DIVINELY CHOSEN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

797 TEAGUE TRL APT 13207
LADY LAKE FL
32159-3152
US

IV. Provider business mailing address

797 TEAGUE TRL APT 13207
LADY LAKE FL
32159-3152
US

V. Phone/Fax

Practice location:
  • Phone: 352-602-5541
  • Fax:
Mailing address:
  • Phone: 352-602-5541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: KEONDRA BURCH
Title or Position: OWNER
Credential:
Phone: 352-602-5541