Healthcare Provider Details

I. General information

NPI: 1164235883
Provider Name (Legal Business Name): DIVINE SENIOR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 5TH ST W
PALMETTO FL
34221-5018
US

IV. Provider business mailing address

820 5TH ST W
PALMETTO FL
34221-5018
US

V. Phone/Fax

Practice location:
  • Phone: 941-721-0426
  • Fax: 941-722-8423
Mailing address:
  • Phone: 941-721-0426
  • Fax: 941-722-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: ROSHAN BISHT
Title or Position: OWNER
Credential:
Phone: 941-721-0426